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TRANSACTIONS 


XAUviVLAZOO  ACAD  EM  Z 

OF  THE 

MEDICINE. 

International  Medical  Congress. 


NINTH  SESSION. 


EDITED  FOR  THE  EXECUTIVE  COMMITTEE 

BY 

JOHN  B.  HAMILTON,  M.  D., 

Secretary-general. 


VOLUME  IV. 


WASHINGTON,  I).  C.,  U.  S.  A. 

1887. 


PUBLISHED  BY  AUTHORITY  OF  THE  EXECUTIVE  COMMITTEE. 


PUBLICATION  COMMITTEE: 

JOHN  B.  HAMILTON,  M.  D., 

Secretary- General . 

A.  Y.  P.  GAENETT,  M.  D., 

Chairman  Local  Committee  of  Arrangements. 

C.  H.  A.  KLEINSCHMIDT,  M.D., 

Librarian  American  Medical  Association. 


L 


WELLCOME  INSTITUTE 

LIBRARY 

Coll. 

welMOmec 

Call 

No. 

VO 

WM.  F.  FELL  & CO.. 
Electrotypers  and  Printers, 

PHILADELPHIA,  PA. 


ERRATA-VOL.  IV. 


Page  IS. — French  title,  for  “Laryngiennee”  read  Laryngiens. 

Page  60. — French  title,  for  “ Perfections  ’’  read  Perfectionnes. 

Page  1U5. — Tenth  paragraph,  for  “cette”  read  cet. 

Page  170. — French  title,  for  “Alimentation  par  rectum”  read  par  le  rectum. 
Page  225. — French  title,  for  “Mercuriala”  read  Mereuriels. 


/ 


- 


PRESENTED  BY 

DR.CHAS,  W.  HITCHCOCK. 

FROM  I HE  LIBRARY  OF 

DR.  H.O.  HITCHCOCK. 


Mn* 


SECTION  XIII— LARYNGOLOGY 


President:  DR.  W.  H.  DALY  Pittsburgh,  Pa. 


VICE-PRESIDENTS. 


Dr.  J.  Baratoux,  Paris,  France. 

Dr.  Bouchut,  Paris,  France. 

Mr.  Lennox  Browne,  London,  England. 

Dr.  J.  Charazac,  Toulouse,  France. 

Dr.  Carl  Deilio,  Dorpat,  Russia. 

Dr.  C.  M.  Desvernine,  Havana,  Cuba. 

Dr.  J.  J.  Kirk  Duncanson,  Edinburg,  Scotland. 

Dr.  Joseph  Gruber,  Vienna,  Austria. 

Dr.  J.  H.  Hartman,  Baltimore,  Md. 

Dr.  G.  V.  Woolen, 


Dr.  Prosser  James,  London,  England. 

Dr.  B.  D.  Moura,  Paris,  France. 

Dr.  J.  0.  Roe,  Rochester,  N.  Y. 

Dr.  0.  Rosenbacii,  Breslau,  Germany. 

Dr.  A.  Schnee,  Nice,  France. 

Dr.  John  Schnitzler,  Vienna,  Austria. 

Dr.  E.  L.  Shurly,  Detroit,  Michigan. 

Dr.  McNiel  Whistler,  London,  England. 

Dr.  F.  Laborde  de  Winthuyssen,  Sevilla,  Spain. 
, Indianapolis,  Ind. 


Wm.  Porter,  m.  d.,  St.  Louis,  Mo. 


SECRETARIES. 

| D.  N.  Rankin,  a.m.  m.  d.,  Allegheny,  Pa. 


COUNCIL. 


Dr.  J.  Dennis  Arnold,  San  Francisco,  Cal. 
Dr.  H.  Blaikie,  Edinburg,  Scotland. 

Dr.  S.  N.  Benham,  Pittsburgh,  Pa. 

Dr.  W.  E.  Casselberry,  Chicago,  111. 

1.  Dr.  Lester  Curtis,  Chicago,  111. 

: , Dr.  H.  H.  Curtis,  New  York,  N.  Y. 

| i Dr.  Andrew  J.  Coey,  Chicago,  111. 


Dr.  Richard  Ellis,  Newcastle-on-Tyne,  England. 
Dr.  Herman  E.  Hayd,  Buffalo,  N.  Y. 

Dr.  E.  Fletcher  Ingals,  Chicago,  111. 

Dr.  Geo.  Mackern,  Buenos  Ayres,  Argentine 
Republic. 

Dr.  M.  C.  O’Toole,  San  Francisco,  Cal. 

Dr.  S.  W.  Pearson,  Baltimore,  Md. 


Vol.  IV— 1 


1 


2 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


FIRST  DAY. 


The  Section  was  called  to  order  promptly  at  3 p.  M.  by  the  President,  Dr.  Daly. 

The  President  announced  that  he  had  been  informed  that  Dr.  Morell  Mackenzie 
was  about  to  receive  the  honor  of  knighthood,  and  hoped,  this  Section  would 
promptly  authorize  an  expression  of  pleasure  and  congratulation  by  cablegram. 

Mr.  Lennox  Browne,  of  London,  moved  a cablegram  be  sent  at  once.  Motion 
seconded  and  carried  unanimously. 

Dr.  J.  Solis-Cohen  moved,  and  motion  seconded,  “that  no  paper  be  read,  if  the 
author  is  not  present,  until  those  present  shall  have  been  read.  ’ ’ Carried. 

INAUGURAL  ADDRESS  OF  THE  PRESIDENT,  W.  H.  DALY,  M.  D. 

Gentlemen — It  is  gratifying  to  see  so  many  of  my  American  confreres  here  to 
redeem  the  pledge  made  for  them  at  Copenhagen,  Denmark,  in  1884,  that  an 
American  welcome  should  be  given  the  International  Medical  Congress,  at  this  its 
ninth  meeting.  It  is  also  a source  of  highest  pleasure  to  meet  those  present  from 
foreign  lands,  many  of  whose  familiar  names  in  the  growing  literature  of  laryngology 
remind  us  that  we  are  not  altogether  new  acquaintances.  With  many  of  us,  our 
memories  revert  at  this  time  with  renewed  freshness  and  pleasure  to  our  last  meet- 
ing in  the  capital  city  of  the  kingdom  of  Denmark,  the  home,  not  only  of 
the  sturdy  Norseman,  but  of  the  most  accomplished  medical  scholars;  where  both 
King  and  Nation  gave  up  their  country  to  the  good  of  the  Congress  during  its  meet-  ; 
ings,  and  where  every  one,  from  ruler  to  peasant,  united  in  showing  their  nation’s  ] 
guests  what  the  full  meaning  of  the  Norseman’s  hospitality  was,  so  earnest,  so  quiet, 
so  restful,  so  complete,  that  it  comes  back  to  us  at  the  end  of  three  years  as  though 
it  was  a quiet,  happy  dream  of  ours  in  a Norseman  fairyland. 

We  scarcely  think  that  it  is  possible  for  us  to  be  so  successful;  but  if  we  can  secure  j 
a degree  of  the  happiness  and  profit  realized  by  all  of  us  in  Denmark  in  1884,  then  I 
think  we  shall  have  been  successful  indeed. 

To  one  and  all,  however,  not  only  to  personal  friends  from  across  the  seas  whose 
familiar  faces  I observe  before  me,  and  to  whom  I am  so  much  indebted  for  early 
and  valuable  training  in  laryngology,  but  to  all,  I bid  a heartfelt  greetiug  and  cordial 
welcome,  and  although  we  may  not  attain  the  perfection  of  the  great  meeting  in 
Copenhagen  in  1884,  yet  I beg  all  of  you  to  feel  that  the  broad  bosom  of  this  j 
beautiful  land  is  happy  in  being  your  resting  place,  and  its  people  feel  the  high  honor 
that  is  accorded  them  in  being  permitted  to  entertain  the  worthy  representative 
medical  men  from  foreign  nations.  We  sincerely  trust  that  none  of  you  will  leave  1 
this  our  nation’s  capital  without  inspecting  its  residential  localities  as  well  as  its  ; 
public  buildings — The  National  Museum,  the  Museum  of  the  Army,  the  Smithsonian 
and  other  institutions.  None  of  these  collections  suffer  by  comparison  with  the 
famous  collections  of  the  old  world.  In  fact,  Washington  City  is  placed  in  the  front 
rank  as  a repository  of  scientific  learning. 


SECTION  XIII — LARYNGOLOGY. 


3 


We  ought  to  congratulate  ourselves  as  laryngologists  in  this  our  second  meeting 
as  an  independent  Section  of  the  International  Medical  Congress,  and  endeavor  to 
have  the  work  of  this  branch  of  medicine  placed  in  every  large  medical  body  as  an 
independent  Section,  as  the  importance  and  growing  excellence  of  its  literature  and 
valuable  practical  work  deserves. 

When  one  looks  back  to  the  state  of  laryngology  in  1876,  and  makes  a comparison 
with  the  present  status  of  it,  it  becomes  a matter  not  only  of  the  utmost  interest, 
but  of  satisfaction  and  pride  to  those  who  have  been  engaged  in  its  study  and 
advancement,  to  note  what,  alone,  its  cognate  branch,  rhinology,  has  done  for  the 
successful  and  rational  .treatment  of  hay  fever.  Before  the  appearance  of  a 
paper  which  I read  before  the  American  Laryngological  Association  in  1881, 
calling  the  attention  of  the  profession  to  some  observations  I made  during  a few 
previous  years,  upon  the  local  predisposing  intra-nasal  causes  of  this  disease,  the 
sufferers  therefrom  had  spent  a rambling  sort  of  life  in  seeking  immunity  from 
what  they  can  now,  in  a large  percentage  of  cases,  easily  get  cured,  permanently  and 
surely,  at  home,  by  a proper  rational  treatment. 

I desire  to  say,  however,  that  the  lamented  Hack,  and  some  other  able  workers 
in  the  same  field,  claimed  more  for  the  plan  of  treatment  I then  advised  than  I ever 
did.  What  I then,  in  1880,  assumed  to  postulate,  I still  find,  after  seven  years, 
strongly  tenable,  viz. , ‘ ‘ Whether  we  are  warranted  in  believing  any  case  of  hay  asthma 
purely  a neurosis,  without  first  eliminating  the  possible  causation  due  to  local,  struc- 
tural or  functional  disease  in  the  naso-pharynx.  ’ ’ Therein  clearly  admitting  that  a 
proportion  of  cases  were  of  the  character  of  neuroses,  but  a far  greater  proportion 
still  depended  upon  a chronic  intra-nasal  disease  upon  which  the  exciting  cause, 
viz. , pollen,  and  other  agents,  act  with  effect ; and  second,  without  this  intrinsic  nasal 
disease  the  exciting  cause  is  innocuous. 

I am  firmly  of  the  belief  that  the  workers  in  our  special  branch  will  yet  make  the 
local  treatment  so  complete  that  we  will  cure  a still  larger  percentage,  even  to  all  the 
cases  of  hay  asthma  that  present  themselves.  This  is  a hopeful  and  zealous  view  of 
the  future  of  hay  fever,  but  I nevertheless  expect  to  see  this  realized. 

There  are  few  laryngologists  but  have  constant  opportunity  of  observing  the 
rapid  development  and  growth  of  puny  children,  after  having  been  under  the  treat- 
ment of  the  throat  specialist,  and  their  noses  and  throats  put  in  proper  order,  so  that 
the  filthy  catarrhal  discharges  are  no  longer  swallowed,  and  the  upper  air  passages 
; are  opened  up,  so  that  during  sleep  they  can  get  a plentiful  supply  of  air  ; hence 
physical  thrift  and  comfort  quickly  change  the  weakly  constitution  to  a strong  one. 

I think  no  working  laryngologist  can  fail  to  note  the  growing  importance  of 
Rhinology,  and  I am  free  to  say  that  the  opinion  I expressed  in  a paper  before  the 
Eighth  International  Medical  Congress  at  Copenhagen,  viz. , ‘ ‘ That  the  laryngologist 
of  the  future  must  be  more  the  rliinologist,  and  the  rhinologist  more  the  surgeon 
than  the  physician,  ’ ’ has  been  fully  borne  out  by  the  evidence  afforded  by  our 
literature  alone. 

There  can  be  no  question  that  a large  proportion  of  the  inflammatory  diseases  of 
the  larynx  are  secondary  to  an  initial  disease  of  the  intra-nasal  cavities,  of  like  inflam- 
matory character.  This  I have  repeatedly  verified  by  years  of  observation,  and 
frequently  publicly  so  stated  in  our  deliberations,  and  I am  pleased  to  say  that  the 
number  of  my  colleagues  who  have  since  also  verified  this  to  their  own  satisfaction 
is  an  ever  increasing  one,  comprising,  as  it  does,  some  of  the  most  successful  and 
distinguished  practitioners  in  this  special  branch  of  medicine.  The  aid  modern 
rhinology  has  been  in  our  successful  prevention  and  treatment  of  internal  and 


4 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


middle-ear  diseases  alone  is  scarcely  calculable.  The  fact  is  apparent  that  no  aurist 
can  be  accomplished  in  his  special  work  who  ignores  the  facilities  alforded  him 
by  a careful  study  of  the  concomitant,  and  too  often  initial,  disease  of  the  intra-nasal 
cavities. 

But,  gentlemen,  time  passes,  and  I must  not  further  dilate  on  the  advancement 
of  our  beloved  specialty  and  its  cognate  branches ; the  bright  minds  who  are  now 
devotees  of  its  sendee,  and  future  workers,  will  place  it  higher  and  higher,  till 
it  reaches  its  zenith  of  excellence  and  usefulness  to  humanity. 

As  you  observe  by  the  printed  programme,  there  is  an  abundance  of  papers,  from 
able  writers  from  many  lands,  upon  most  attractive  subjects,  and  the  valuable  time 
of  the  Section  must  not  be  taken  up,  either  by  your  President  or  any  one  else,  to  the 
exclusion  of  others.  I will,  therefore,  set  the  example  of  brevity  by  making  my  address 
short.  I feel  I have  your  kind  wishes,  and  that  you  will  aid  me  in  expediting 
the  work  of  the  Section  from  day  to  day,  confining  ourselves  strictly  to  the  time  per- 
mitted to  each  member  under  the  rules,  viz. , twenty  minutes  for  the  reading  of  a 
paper  and  ten  minutes  for  each  speaker  engaging  in  the  discussion  thereof.  I shall 
hope  that  each  member  will  be  promptly  here  at  the  hour  to  which  we  adjourn,  so 
that  we  can  begin  our  work  and  continue  it  without  undue  haste  as  the  session 
advances. 

But,  friends,  we  are  solemnly  reminded  in  these  living  moments,  as  we  enjoy  our 
happy  greetings  of  old  friends  and  new  “from  lands  of  sun  to  lands  of  snow,” 
that  there  is  an  increasing  number  of  the  goodly  names  of  our  honored  dead,  who 
worked  and  won  fame  in  the  field  we  now  cultivate  ; while  they  are  personally  the 
silent  members  of  this  our  Ninth  International  Medical  Congress,  yet  through  every 
one  of  you  their  names,  and  voices,  and  words  of  wisdom  will  be  heard,  as  you  speak 
from  this,  for  the  time  being,  the  World’s  Medical  Forum,  to  your  absent  colleagues 
in  every  land  and  clime.  Their  names  are  on  the  lips  of  every  student  of  laryngology, 
and  their  words  will  always  stand  a part  of  its  growing  and  valuable  literature  ; and 
while  then-  fame  is  our  pride,  let  it  also  be  our  aim  to  emulate  the  higher  traits  of 
character  and  the  ability  that  won  for  our  Elsberg,  Krishaber,  Foulis,  Bruns,  Walden- 
berg,  Buro,  Bocker  and  Hack,  the  distinction  that  made  their  teachings  as  beacon 
lights  to  guide  their  less  gifted  brethren  in  the  fields  of  laryngological  science.  Oh 
honored  dead,  we  in  spirit  strew  flowers  on  your  tombs,  and  join  hand  in  hand  while 
we  bless  the  memory  of  your  worthy  lives  and  mourn  the  events  of  your  too 
untimely  deaths.  A part  of  this  number  were  young  men,  cut  off  in  the  growing  beauty 
and  strength  of  manhood,  with  all  the  zeal  and  enthusiasm  of  their  scientific  labors 
yet  fresh  upon  them.  May  the  earth  rest  lightly  over  them  in  the  respective  lands 
where  their  devoted  bodies  lie,  the  lameuted,  the  honored,  dead  of  our  ranks. 


DISCUSSION  ON  EPISTAXIS. 

Prof.  E.  Fletcher  Ingals,  of  Chicago,  opened  the  discussion  on  Epistaxis,  it 
being  one  of  the  subjects,  selected  for  special  discussion.  He  remarked,  this  is  an  old 
subject,  on  which  there  is  little  to  say,  but  we  hope  its  discussion  may  call  out  some 
new  thoughts  from  some  of  the  many  workers  in  this  field.  It  is  of  much  import- 
ance, because  of  the  frequency  of  the  affection,  and  therefore  anything  t hat  may  add 
to  the  general  fund  of  our  knowledge  regarding  it  is  valuable  to  the  whole  profession. 


SECTION  XIII — LARYNGOLOGY. 


5 


The  ordinary  cases  of  the  disease  occurring  in  children  and  young  adults  require 
no  treatment  whatever,  as  the  bleeding  is  nature’s  attempt  to  relieve  plethora,  or  it 
is  so  slight  that  any  of  the  many  popular  methods  will  check  it  in  a few  minutes; 
but  when  bleeding  is  persistent,  or  when  it  occurs  frequently  in  such  amount  as  to 
debilitate  the  patient,  it  must  receive  our  careful  attention. 

In  such  cases  constitutional  remedies,  such  as  ergot,  gallic  acid  and  iron,  have 
been  long  recommended,  and  they  may  probably  be  tried,  but  I have  little  confidence 
in  their  efficiency.  In  most  of  these  cases  topical  measures  must  be  employed.  Many 
times  the  bleeding  may  be  checked  by  insufflations  of  cocaine,  which  is  the  most 
agreeable  to  the  patient,  or  by  tannin,  gallic  acid  or  matico,  any  of  which  may  be 
used  without  causing  great  discomfort.  If  the  insufflations  do  not  succeed,  plugging 
should  be  resorted  to.  The  post-nasal  tampon  is  efficient  and  is  commonly  employed, 
but  it  causes  great  discomfort,  and  is  liable  to  set  up  inflammation  of  the  middle 
ear,  with  serious  consequences.  A number  of  deaths  have  been  reported  from 
the  inflammation  which  it  has  caused,  therefore  it  should  not  be  employed  if  it  can 
be  avoided,  and  in  nearly  every  case  equally  good  or  better  results  can  be  obtained 
by  tamponing  the  naris  from  in  front.  If  the  posterior  plug  is  used,  a short  string 
should  be  left  hanging  down  from  it,  behind  the  palate,  to  facilitate  its  removal.  The 
method  of  tamponing  which  I have  employed  with  most  satisfaction  is  done  with  a 
strip  of  surgeon’s  gauze,  about  an  inch  in  width  and  three  or  four  feet  in  length, 
which  has  been  saturated  with  a mixture  of  tannin  rubbed  up  in  water  to  the  con- 
sistence of  thin  syrup.  The  nostril  being  distended,  the  end  of  this  strip  should  be 
folded  over  a flat  probe  and  earned  quickly  to  the  back  of  the  nasal  cavity,  and  sub- 
sequently fold  after  fold  is  pushed  in  more  slowly  until  the  whole  cavity  is  filled.  It 
is  important  to  carry  in  the  first  fold  quickly,  otherwise  the  blood  will  cause  it  to 
adhere  to  the  walls  before  it  has  reached  its  proper  position.  As  this  plug  must  be 
kept  in  situ  sometimes  for  many  hours,  it  is  well  to  make  a free  insufflation  of  iodo- 
form just  before  its  introduction.  In  some  cases  it  will  be  found  very  advantageous 
to  tie  several  threads  of  strong  silk,  about  two  inches  apart,  to  the  end  of  the  strip  of 
gauze  which  is  just  introduced.  These  are  allowed  to  hang  from  the  nostril;  the  end 
of  gauze  to  which  they  are  fastened  is  pushed  into  the  naso-pharynx,  and  after  the 
naris  has  been  partially  filled  the  threads  are  drawn  upon,  one  after  another,  so  as 
to  thoroughly  plug  the  posterior  naris.  After  the  immediate  danger  is  over,  a 
careful  inspection  of  the  naris  will,  in  the  great  majority  of  cases,  reveal  a small  erosion 
or  ulcer  from  which  the  blood  has  escaped.  When  this  has  been  thoroughly  cauter- 
ized a cure  may  be  expected.  For  cauterization  nitrate  of  silver  may  be  employed, 
but  the  galvano-cautery  is  far  preferable.  In  some  cases,  viz. , those  depending  on 
the  hemorrhagic  diathesis  or  extreme  plethora,  this  may  not  effect  a cure,  but  fortu- 
nately these  cases  are  extremely  rare. 

Dr.  I.  Hermann,  of  Washington,  D.C.,  remarked — I have  listened  with  great 
interest  to  the  discussion  on  this  interesting  subject.  I should  like  to  say  a few 
words  on  a remedy  for  epistaxis  which  has  not  been  mentioned  among  the  different 
cures  to-day.  They  are,  of  course,  all  very  valuable,  but  we  sometimes  meet  cases 
where  they  all  seem  to  fail.  Such,  at  least,  has  been  my  experience  in  a number  of 
cases,  and  in  one  case  particularly,  which  I will  describe  shortly.  I had  a lady 
under  treatment  for  acute  otitis  media,  and  had  to  make  the  paracentesis  tympani, 
using  also  the  nasal  catheter  to  remove  the  pus  from  the  tympanic  cavity.  I am  sure 
I did  not  produce  a lesion  of  the  nasal  membrane  with  the  catheter,  but  on  the 
evening  of  the  following  day  I was  called  to  the  lady,  who  had  been  bleeding  at  the 


6 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


nose  for  several  liours.  I found  her  indeed  in  quite  an  alarming  condition,  as  she 
was  already  quite  anaemic  from  having  injudiciously  nursed  a fifteen  months  old 
baby,  and  this  loss  of  blood  was  rather  too  much  for  her.  I applied  cocaine  in  sub- 
stance and  in  bulk  without  effect,  also  Morell  Mackenzie’s  tannic  and  gallic  acid 
mixture,  as  well  as  the  anterior  tampon;  still  the  blood  continued  to  flow  in  front  as 
well  as  in  the  pharynx.  Then  I thought  of  a remedy  I have  sometimes  used,  and 
called  for  cracked  ice,  filled  both  nostrils  with  it,  and  put  a small  bag  on  the  bridge 
of  the  nose.  Then  I made  the  anterior  tamponade  in  both  nostrils.  This  stopped 
the  bleeding  effectively,  and  another  slight  attack  on  the  following  day  was  also  at 
once  stopped  by  this  application.  I found  also,  on  inquiry,  that  the  bleeding  of  the 
nose  was  simultaneous  with  a flow  of  blood  from  the  uterus.  I have  used  this 
remedy  for  epistaxis  before,  on  several  occasions.  I do  not  hesitate  to  commend  it  to 
the  profession  as  a very  superior  and  convenient  remedy,  where  others  fail. 

Dr.  Walton  Browne,  of  Belfast,  Ireland,  said — I believe  in  the  treatment  of 
epistaxis;  we  should  trust  to  plugging  from  the  anterior  nares  by  a strip  of 
lint  impregnated  with  powered  alum ; remove  it  at  the  end  of  twenty-four  hours 
by  gentle  syringing,  and  then  plug  with  cotton  wool  saturated  with  hazaline.  I 
would  especially  refer  to  the  treatment  of  epistaxis  by  my  friend  Dr.  Harkin,  of 
Belfast,  namely,  counter-irritation  over  the  region  of  the  liver,  with  good  results. 

Mr.  Lennox  Browne,  of  London,  related  a case  to  show  that  it  was  sometimes 
unwise  to  arrest  a disposition  to  epistaxis  in  persons  past  middle  age,  even  when 
appearing  to  proceed  from  purely  local  causes  in  the  nostril.  He  also  drew  atten- 
tien  to  recent  experiments  which  tended  to  prove  that  the  astringent  properties  of 
tannin  have  been  much  exaggerated. 

Dr.  M.  It.  Coomes,  of  Louisville,  Ivy.  related  a case  where  a tampon  had  re- 
mained in  the  nostril  by  mistake  for  seven  months;  spoke  of  the  plan  of  holding  or 
compressing  the  nose,  and  the  introduction  of  a piece  of  bacon  in  the  nostril. 

Dr.  John  M.  Foster,  of  Richmond,  Ky.,  related  a case  of  epistaxis  due  to  heart 
disease  relieved  by  the  use  of  digitalis,  and  spoke  of  the  influence  of  scrofula  in 
bringing  about  the  hemorrhagic  diathesis. 

In  closing  the  discussion,  Prof.  Ingals  inquired  of  the  other  speakers  as  to 
whether  ice  or  alum,  as  recommended  by  Dr.  Browne,  of  Belfast,  caused  pain. 
He  was  answered  in  the  negative,  and  therefore  he  thought  well  of  both  methods. 
He  had  no  experience  with  bacon,  recommended  by  one  of  the  speakers.  The  method 
of  compressing  the  nostrils  until  the  blood  had  coagulated  had  been  referred  to  as  Dr. 
Roe’s  method;  but  he  was  sure  that  his  friend  from  Rochester,  if  present,  would  not 
father  a method  which  had  been  in  common  use  for  five  thousand  years — since 
according  to  one  of  the  speakers  of  the  session,  rhinologists  first  began  their  practice. 


SECTION  XIII — LARYNGOLOGY.  7 

A CONTRIBUTION  ON  THE  CAUSES  AND  TREATMENT  OF  SO- 
CALLED  HAY  FEVER,  NASAL  ASTHMA,  AND  ALLIED  AFFEC- 
TIONS, CONSIDERED  FROM  A CLINICAL  STANDPOINT. 

UN  RAPPORT  SUR  LES  CAUSES  ET  LE  TRAITEMENT  DE  L’ASTHME  DE  FOIN 
ET  DES  AFFECTIONS  SEMBLABLES  CONSIDEREES  AU  POINT 
DE  VUE  CLINIQUE. 

EIN  BEITRAG  ZUR  ATIOLOGIE  UND  BEHANDLUNG  DES  SOGENANNTEN  HEU-ASTHMAS 
UND  VERWANDTER  AFFECTIONEN,  VOM  KLINISCHEN  STANDPUNKT 

BETRACHTET. 

BY  RICHARD  HENRY  THOMAS,  M.D., 

Of  Baltimore,  Md. 

Mr.  President  and  Gentlemen  of  the  Section. — In  asking  you  to  consider 
with  me  the  subject  of  the  nasal  neuroses,  I do  so  with  the  object  of  relating  chiefly  my 
own  experience,  with  a hope  of  thereby  contributing  to  the  solution  of  some  of  the 
vexed  questions  in  regard  to  this  class  of  diseases. 

There  are  those  who  claim  that  the  occurrence  of  nasal  reflexes  depends  chiefly  upon 
a condition  of  neurasthenia,  or  some  disturbance  of  the  general  nervous  system;  others, 
that  they  are  due  to  obstructive  disease  of  the  nasal  passages,  or  to  some  well  defined 
intra-nasal  disorder.  Again,  it  has  been  urged  that  there  exist  in  the  upper  air  pas- 
sages certain  special  areas,  such  as  “ the  reflex  sensitive  area,”  and  that  if  these  areas 
become  diseased,  or  irritated  by  the  presence  of  a polyp,  or  an  opposing  hypertrophy, 
etc.,  they  will  give  rise  to  reflex  phenomena.  Others  consider  that  the  underlying 
cause  consists  in  a congenital  peculiarity  of  structure,  either  in  the  nerve  centres  or  end- 
ings, that  render  them  liable  to  take  on  perverted  or  excessive  action  when  exposed  to 
certain  exciting  causes;  that  this  condition,  though  obscure,  is  pathological,  and  is 
greatly  affected  by  the  general  health  of  the  individual,  and  by  various  diseases  of  the 
upper  air  passages. 

For  reasons  which  I am  about  to  submit,  I incline  to  this  last  view,  as  opposed  to 
the  others  I have  mentioned.* 

1.  Neurasthenia. — While  it  is  true  that  many  of  those  in  whom  we  observe  the  pres- 
ence of  nasal  neuroses  are  either  neurasthenics  or  show  evidence  of  some  disturbance 
of  the  general  nervous  system,  and  while  this  general  condition,  when  present,  undoubt- 
edly is  a very  important  factor  in  maintaining  and  increasing  the  violence  of  the  attacks, 
yet  the  frequency  with  which  we  meet  with  the  reflex  phenomena  as  the  only  evidence 
of  nervous  disorder,  shows  that  neurasthenia,  or  any  condition  of  the  general  nervous 
system,  is  not  of  itself  the  necessary  predisposing  cause.  This  proposition  is  further  sup- 
ported Jay  the  fact  that  we  not  infrequently  see  neurasthenics  suffering  from  various 
forms  of  nasal  disease,  who  present  no  evidence  of  reflex  phenomena  referable  to  the 
upper  air  passages. 

2.  Obstructive  Diseases  of  the  Nasal  Passages. — These  are  undoubtedly  very  frequently 
associated  with  hay  fever,  nasal  asthma,  etc.,  but  that  this  condition  is  not  in  itself  a 
principal  factor  in  producing  the  attack  is  shown  lay  the  following  reasons: — 

(a)  In  the  majority  of  cases  where  I have  observed  this  condition  (whether  arising 
from  polypi,  hypertrophies,  deflected  septum,  etc.,)  there  have  been  no  reflex  phe- 
nomena at  all,  even  in  neurasthenic  individuals.  While  this  condition  usually  aggra- 


* In  the  list  of  theories  I have  not  included  that  which  considers  that  a specific  action  belongs 
to  the  pollen  of  certain  plants,  as  this  doctrine  is  held  by  but  few,  and  they  are  decreasing  in 
number. 


8 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


vates  the  attacks,  it  cannot  be  said  to  do  so  invariably,  for  in  one  of  ray  patients  the 
symptoms  are  generally  ameliorated  when  the  nasal  passages  become  occluded,  either  by 
swelling  or  secretion. 

( b ) In  typical  cases  of  nasal  asthma,  I have  observed  patients  in  whom  there  was  at 
no  time  nasal  obstruction,  though  this  condition  is  not  so  common  as  the  opposite. 

(c)  Cases  have  been  reported,  though  I have  not  seen  any,  where  reflex  phenomena 
of  nasal  origin  were  associated  with  an  atrophic  condition  of  the  nasal  tissues. 

(d)  It  is  generally  possible  in  hay-fever  patients  to  excite  a temporary  attack  at  any 
time,  by  touching  the  sensitive  areas  in  the  upper  air  passages  with  a probe,  and  this 
independently  of  the  presence  or  not  of  nasal  obstruction. 

3.  The  same  remarks  apply  to  nasal  and  pharyngeal  diseases  generally,  that  can  be 
detected  by  the  ordinaiy  methods  of  rhinoscopic  examination.  They  all  may  or  may 
not  be  accompanied  by  reflex  phenomena.’  We  may,  therefore,  conclude  that  the  pri- 
mary cause  of  the  nasal  neuroses  is  not  to  be  looked  for  in  any  of  them,  while  it  is 
undoubtedly  true,  both  in  regard  to  neurasthenic  and  non-neurasthenic  individuals, 
that  their  presence  may  greatly  aggravate  and  prolong  the  attacks,  and  perhaps  even 
develop  a latent  tendency  thereto. 

4.  The  Existence  of  Sensitive  Areas. — These  have  been  variously  defined  by  various 
'observers.  Some  have  been  inclined  to  limit  them  to  special  places.  Others  have 

admitted  that  any  part  of  the  upper  air  passages  may  be  sensitive,  but  claim  that  there 
are  special  areas  which  are  most  generally  sensitive,  and  on  this  claim  they  base  their 
own  theories  as  to  the  aetiology  of  nasal  neuroses. 

On  this  point  I have  instituted  two  series  of  observations.  The  first  was  to  dis- 
cover the  sensitive  area,  or  areas,  in  those  who  were  affected  with  some  of  the  forms  of 
nasal  or  pharyngeal  reflex  disturbance.  The  second  was  to  discover  any  sensitive  areas 
that  might  exist  in  cases  where  the  upper  air  passages  were  normal,  or,  if  pathological, 
not  associated  with  reflex  disturbance.  Of  course,  I excluded  all  cases  where  there 
was  any  destructive  disease.  In  carrying  out  these  observations,  I found  that  different 
individuals  vary  greatly,  not  only  in  the  ease,  but  in  the  rapidity  with  which  they 
respond  to  the  touch  of  the  probe.  This  makes  it  important  to  pause  after  touching 
one  point  before  proceeding  to  another,  for  if  this  be  not  done,  reflex  phenomena  really 
due  to  irritation  of  one  part  may  be  wrongly  ascribed  to  another. 

In  the  first  series  of  cases,  that  is,  those  where  the  reflex  phenomena  were  present, 

I have  found,  as  far  as  I have  gone,  that  it  is  absolutely  impossible  to  say  positively 
that  one  part  of  the  intra-nasal  passages  is  more  sensitive  than  another.  In  every  case 
some  area  of  special  sensation  was  to  be  found,  but  this  area  would  vary  in  every  case, 
and  in  one  or  two  instances  could  only  be  located  in  one  nostril.  In  others,  the  sensi- 
tive area  would  be  located  in  one  nostril  at  one  point,  and  in  the  other  at  another  point 
not  corresponding  to  the  first.  I find  I have  noted  in  different  cases  the  floor  of  the 
nostrils,  any  portions  of  the  turbinated  bodies,  the  whole  of  the  septum,  partg  of  the 
pharynx.  There  is  a slight  predominance  in  favor  of  the  middle  and  posterior' 
portions  of  the  nasal  passages,  and  of  any  part  of  the  septum,  especially  that 
portion  supplied  by  the  olfactory.  In  two  cases  almost  every  portion  of  the  intra- 
nasal tissues  appeared  equally  sensitive.  These  observations  were  all  carried  on  during 
the  intervals  between  the  attacks,  no  observation  taken  during  an  attack  or  in  the 
hay-fever  season  having  been  noted  in  the  preparation  of  this  paper.  The  reflex  phe- 
nomena brought  out  in  these  cases  were  : besides  the  usual  laclirymation,  violent  parox- 
ysmal sneezing,  disturbances  of  respiration,  such  as  temporary  asthmatic  dyspnoea, 
headache,  etc. 

In  the  second  series  of  cases,  that  is,  in  those  where  there  were  no  reflex  disturb- 
ances, I found,  generally,  that  it  was  impossible  by  ordinary  probing  to  produce  any 
result  beyond  lachrymatiou,  slight  sneezing  and,  at  times,  a very  slight  expiratory  effort. 


SECTION  XIII — LARYNGOLOGY. 


9 


The  second  was  very  often  the  last,  generally  absent.  There  was  in  some  individuals 
of  this  class  a very  high  degree  of  ordinary  hypermstliesia  in  the  nasal  tissues,  so  that 
a slight  touch  of  the  probe  would  cause  decided  pain  or  great  tickling.  In  these  there 
was  no  reflex  phenomena  produced  beyond  laehrymation.  In  this  class  I have  not  been 
able  to  discover  any  area  of  special  sensation,  the  slight  phenomena  produced  being 
called  forth  about  equally  well  from  the  various  parts  of  the  intra-nasal  tissues. 

While  my  observations  are  still  in  progress,  the  results  thus  far  incline  me  to 
adopt  the  opinions  of  those  who  maintain — 

(0)  That,  as  a rule,  there  exists  normally  in  the  upper  air  passages  no  special  “ reflex 
sensitive  area.”  This  view  is  strengthened  by  the  occurrence  of  polypi,  etc.,  where 
they  can  irritate  the  so-called  sensitive  areas  without  producing  reflex  phenomena. 

(b)  When,  under  pathological  conditions,  such  an  area  is  present,  it  may  exist  in 
any  part  of  the  upper  air  passages.  If  this  view  be  correct,  we  must  accept  the  theory 
of  Lublinski,  that  in  the  production  of  a paroxysm  the  olfactory,  the  trigeminus  and 
the  sympathetic  may  be  involved. 

5.  Congenital  Peculiarity  of  Structure. — As  the  other  theories  I have  mentioned  are 
not  sufficiently  sustained,  we  seem  driven  to  the  theory  that  there  is  a peculiar  condi- 
tion, in  the  nerve  endings  (or  perhaps  in  the  nerve  centres),  that  renders  them  liable  to 
take  on  excessive  or  perverted  action  when  exposed  to  certain  forms  of  irritation. 
Idiosyncrasy  is,  according  to  Jonathan  Hutchinson,  “to  a large  extent  a diathesis 
brought  to  a point.”  I do  not  use  the  term  as  a means  for  hiding  ignorance  or  dis- 
couraging research.  But  our  knowledge  is  not  yet  sufficiently  accurate  to  lay  aside  the 
expression.  The  existence  of  an  idiosyncrasy  always  denotes  a pathological  condition 
which  is  still  obscure.  The  pathological  condition,  however,  occasions  no  disturbance 
until  an  exciting  cause  is  present,  and  the  readiness  and  violence  with  which  it  will 
respond  to  these  excitants  depends  greatly  upon  the  condition  of  the  upper  air  passages 
and  of  the  general  nervous  system . Why  one  irritant  should  produce  an  attack  in  one 
person  and  be  harmless  to  another  is,  as  far  as  our  present  knowledge  goes,  explicable 
only  on  the  supposition  of  an  idiosyncrasy. 

The  exciting  causes  may  be  classed  as  follows  : (1)  Inert  substances  floating  in  the 

air,  such  as  pollen,  etc.  (2)  Psychical  impressions.  (3)  Meteorological  changes,  and 
the  effect  of  sunlight  and  wind.  (4)  Morbid  changes  and  new  growths  in  the  upper  air 
passages.  (5)  Irritation  reflected  from  distant  parts  of  the  body. 

(1)  Substances  Floating  in  the  Air. — In  the  class  of  cases  affected  by  this  variety  of 
irritants,  the  periodicity  depends  upon  the  return  of  the  irritant.  Thus,  in  the  case  of 
a colored  man  who  presented  himself  at  my  clinic,  the  man  would  be  free  from 
attacks  all  the  year  round,  working  on  a farm  in  the  country,  but  could  not  for  a moment 
enter  a room  where  oysters  were  being  opened  without  having  a decided  attack.  In  a 
medical  student  the  odor  of  a dissecting  room  was  found  to  have  a similar  effect. 
Among  the  external  irritants,  other  than  those  just  mentioned,  floating  in  the  atmos- 
phere, which  I have  noted  as  producing  a paroxysm  in  my  patients,  are  the  following  : 
The  pollen  of  rag-weed,  luxuriant  vegetation  generally,  Indian  corn  in  tassel,  the  smell 
of  flowers,  dust,  wheaten  and  other  kinds  of  flour  and  meal,  the  odor  of  tobacco,  the 
dust  of  a preparation  called  “soapine,”  the  dust  of  a railway  train,  etc. 

(2)  Psychical  Impressions. — These  are  at  times  sufficient  to  act  as  an  exciting 
cause  in  a sensitive  person,  as,  e.  g.,  the  production  of  an  attack  by  the  sight  of  an  arti- 
ficial rose,  reported  by  Dr.  I.  N.  Mackenzie.  This  interesting  case  has,  as  Dr.  Bosworth 
points  out,  no  bearing  on  the  question  as  to  the  power  of  the  odor  of  flowers  to  pro- 
duce an  attack  without  psychical  impressions,  as  it  is  not  at  all  likely  that  the  result 
would  have  been  brought  about  had  it  not  been  for  the  former  experiences  of  the 
patient  with  real  roses.  I have  seen  a patient  become  affected  by  the  presence  of 
flowers  in  a room  before  he  knew  they  were  there.  In  my  own  person  I have  noticed 


10 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


the  effect  of  another  form  of  mental  impression.  Although  not  subject  to  hay  fever,  I 
frequently  have  an  attack  of  something  like  it  for  about  half  an  hour  after  treating  a 
severe  case. 

(3)  Atmospheric  Changes,  etc. — The  effect  of  these  is  so  well  known  that  I will  merely 
refer  to  an  interesting  case  that  has  lately  presented  itself  to  me.  The  patient  suffers 
violently  from  asthma  of  naso-pharyngeal  origin.  The  attacks  only  come  on  during 
the  three  summer  months.  The  hotter  the  day  the  more  comfortable  she  is,  hut  the 
sudden  cooling  of  the  atmosphere  by  a thunder  storm,  either  where  she  is  or  in  the 
near  vicinity,  will  bring  on  an  attack.  The  peculiarity  in  her  case  is  that  if  a thunder 
storm  occur  in  May,  after  never  so  hot  a day,  it  will  not  affect  her. 

(4  and  5)  New  Growths  and  other  Morbid  Changes  in  the  Upper  Air  Passages. — The 
influence  of  these  has  been  so  exhaustively  discussed  of  late  years,  that  it  need  only  be 
referred  to  here.  Neither  will  I take  your  time  to  dwell  upon  the  power  of  irritation 
in  other  organs  to  produce  reflex  disturbance  of  the  respiratory  tract.  Of  the  connec- 
tion between  irritation  of  the  genital  apparatus  and  that  of  the  nose,  I have  not  had 
any  experience  as  far  as  genuine  hay  fever  cases  are  concerned.  In  a lady  who  suffered 
severely  from  migraine  of  nasal  origin  (which  has  since  largely  yielded  to  intra-nasal 
treatment)  the  first  symptom  would  he  occlusion  of  the  nostrils  and  a simultaneous 
appearance  of  a leucorrhceal  discharge  from  the  vagina,  which  would  abate  with  the 
abatement  of  the  nasal  symptoms. 

If  the  views  advanced  in  this  paper  be  correct,  it  follows  that,  in  the  history  of  a 
paroxysm,  the  hyperasmia  and  swelling  are  secondary  phenomena,  the  underlying 
cause  being  the  excitation  of  the  nerve  endings  (or  centres),  which  are  in  a condition  to 
respond  to  the  irritant  acting  upon  them. 

I have  noted,  in  common  with  others,  the  marked  influence  of  heredity,  but  not  to 
the  same  extent  of  race  or  station  in  life.  While  the  majority  of  my  patients  have 
belonged  to  the  more  educated  and  intellectual  classes,  I have  seen  cases  in  every  class 
of  life,  and  not  only  in  the  Caucasian,  but,  in  two  instances,  in  the  negro. 

Treatment. — This  may  be  palliative  or  curative.  The  palliative  consists  in  various 
applications  and  internal  remedies  used  at  the  time  of  the  attack.  Of  these  there  are 
many,  and  none  of  them  are  of  much  permanent  value.  Their  constant  use  is  not 
without  risk  to  the  parts.  This  can  certainly  be  predicated  of  local  applications,  such 
as  cocaine  and  other  powerful  drugs. 

Traveling  is  often  a complete  temporary  relief.  The  precise  cause  for  this  is  not 
always  easy  of  explanation.  A patient  of  mine,  who  for  years  was  a sufferer,  lived  in  a 
county  in  Maryland  where  the  vegetation  was  luxuriant.  One  year  he  spent  the  season 
in  another  county  where  the  conditions  were  the  same,  and  where  a number  of  the 
inhabitants  are  affected  with  hay  fever.  Yet  he  escaped  entirely  that  year.  The  same 
individual  would  not  be  entirely  free  from  attacks  on  a coasting  vessel  that  kept  within 
fifteen  to  fifty  miles  from  shore,  and  this  independently  of  the  direction  of  the  wind. 

The  proper  course  to  pursue  is  the  one  that  looks  to  a radical  cure.  To  accomplish ' 
this  we  must  use,  in  the  majority  of  cases,  both  constitutional  and  local  treatment.  If 
we  take  Jonathan  Hutchinson’s  definition,  above  referred  to,  the  presence  of  an  idio- 
syncrasy should  no  more  discourage  treatment  than  a diathesis.  The  most  important 
part  of  the  treatment  is  the  local,  for  the  introduction  of  which  we  are  indebted  to  our 
honorable  President,  Dr.  W.  H.  Daly.  This  has  two  objects : 1st,  to  cure  any  coexisting 
disease  in  the  nose  or  throat ; and,  2d,  to  search  out  carefully  and  locate  the  sensitive 
area  or  areas  that  may  exist  in  the  upper  air  passages  and  cauterize  them,  an  operation 
rendered  nearly  painless  since  the  introduction  of  cocaine.  On  the  first  indication  it  is 
needless  to  dwell.  For  the  second  I greatly  prefer  the  galvano-cautery,  although  other 
caustics,  such  as  glacial  acetic  acid,  may  be  used  instead.  I have  employed  the  galvano- 
cautery  constantly  for  four  years,  and  am  more  and  more  impressed  with  its  adapt- 


SECTION  XIII — LARYNGOLOGY. 


11 


ability  and  safety,  when  used  with  the  proper  precautions.  After  the  applications,  the 
nasal  passages  should  be  carefully  cleansed  with  some  mild  antiseptic  solution  (as 
Dobell’s),  and  the  eschars  removed  as  soon  as  possible,  especially  where  the  cauteri- 
zation has  been  made  on  a surface  that  nearly  approaches  the  opposite  wall  of  the  naris. 
I frequently  give  iron  and  quinine  internally  after  an  application. 

The  most  important  rule  to  be  observed  in  carrying  out  the  treatment  is  to  be 
thorough.  So  long  as  any  sensitive  area  remains,  the  patient  is  not  cured.  The  main 
treatment  must  be  carried  out  betweeu  the  seasons  for  the  attacks,  and  I prefer  to  begin 
as  soon  as  the  attack  is  over.  It  is  important,  also,  to  see  the  patient  during  the  next 
season,  as  it  is  impossible  to  discover  all  the  sensitive  areas  until  the  season  arrives. 
The  remaining  sensitive  spots  are  then  to  be  cauterized. 

I have  seen  the  most  gratifying  results  by  following  this  method,  though  I have  one 
case  on  record  where  the  patient  was  cured  without  the  use  of  any  cautery,  but  only  by 
simple  applications  of  astringents  and  general  treatment. 

In  cauterizing,  my  method  is  to  destroy  as  little  tissue  as  possible.  The  cavernous 
tissue  is  a normal  one,  and  the  process  of  engorgement  and  swelling  which  occurs  in  the 
varying  states  of  the  temperature  and  of  the  atmosphere  is  a normal  one,  and,  in  proper 
limits,  preservative  to  the  health.  To  attempt,  then,  anything  like  its  entire  extirpa- 
tion, even  if  that  were  possible,  except  where  it  is  clearly  required,  is  unwise. 

At  the  same  time,  constitutional  measures,  chiefly  addressed  to  the  nervous  system, 
are  generally,  though  not  always,  indicated.  The  drugs  I most  frequently  use  are  the 
valerianates  of  ii-on,  quinine  and  zinc,  arsenic  or  hydrobromic  acid  (Gardner’s  syrup). 
In  all  cases  of  debility  the  general  health  must  be  built  up  by  the  usual  tonics.  Each 
case  has  to  be  made  a separate  study.  If  the  treatment  be  properly  carried  out,  the 
prognosis  for  a radical  cure  is  decidedly  good.  Had  time  permitted,  I should  have 
illustrated  this  paper  by  more  cases  from  my  own  practice,  but,  as  it  does  not,  I must 
be  content  to  present  these  observations  as  a r6sum6  of  my  work  up  to  date. 


HAY  FEVER. 

ASTHME  DE  POIN. 

HEU-ASTHMA. 

BY  ISRAEL  P.  KLINGENSMITH,  M.D., 

Of  Blairsville,  Pa. 

At  no  time  in  the  world’s  history,  since  the  day  Dr.  John  Bostock,  in  1819,  presented 
the  first  formal  paper  on  this  subject  to  the  London  Medico-Chirurgical  Society,  have 
more  eager  scientific  workers  been  in  the  field  in  the  pursuit  of  knowledge  and  its 
practical  application  to  disease  In  no  subject  can  you  find  a better  proof  of  this  fact, 
than  in  the  disease  now  under  consideration.  I will  not  occupy  your  valuable  time  by 
giving  a detailed  history  of  the  symptoms,  course  and  duration  of  the  disease,  but  will 
confine  myself  to  submitting  to  your  consideration  the  results  of  my  investigations  so 
far  as  they  bear  broadly  and  directly  upon  the  method  of  treatment  I propose  to  advo- 
cate. In  very  few  diseases  do  we  find  such  a diversity  of  opinion  in  regard  to  the  cause, 
as  in  hay  fever.  Bostock  attributed  it  to  heat,  while  his  contemporaries  differed  on 


12 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


this  point.  Since  that  period  many  theories  have  been  advanced,  but  considerable 
diversity  of  opinion  exists  even  at  the  present  time.  Until  within  the  last  five  or  six 
years,  inquiry  has  been  directed  to  the  investigation  of  the  exciting  cause  of  the  attack, 
and  the  predisposing  or  more  important  causes  of  the  disease  have  been  overlooked. 
Most  of  the  literature  upon  the  subject  of  hay  fever,  hay  asthma,  autumnal  catarrh,  or 
by  whatever  name  it  may  be  designated,  is  devoted  to  the  extraneous  or  exciting  causes 
of  the  malady  in  question,  and  numerous  remedies,  which  serve  simply  to  divert  the 
mind  of  the  sufferer,  without  resulting  in  any  practical  benefit,  are  suggested.  Each 
patient  coming  under  our  observation  should  be  subjected  to  a thorough  rhinoscopic 
examination,  allowing  all  fine-spun  theories  and  extrinsic  causes  to  take  care  of  them- 
selves. To  Dr.  W.  H.  Daly,  of  Pittsburgh,  Pa.,  belongs  the  honor  of  first  calling  the 
attention  of  the  profession  to  the  important  part  which  diseases  of  the  naso-pharyngeal 
cavities  play  in  the  production  of  hay  fever,  who,  in  a paper  read  before  the  American 
Laryngological  Association,  in  May,  1881,  showed  that  the  exciting  causes  of  the  disease 
are  innocuous  in  those  cases  in  which  disease  of  the  naso-pharyngeal  cavities  does  not 
exist,  and  proved  further,  from  clinical  evidence,  that  the  disease  is  a curable  one,  by 
removing  the  intrinsic  local  cause  and  restoring  the  parts  to  a normal  condition.  The 
succeeding  year  Dr.  John  O.  Roe,  of  Rochester,  N.  Y.,  read  a paper  before  the  Medical 
Society  of  the  State  of  New  York,  practically  corroborating  the  investigations  of  Dr. 
Daly.  In  1884,  Dr.  Hack,  of  Freibui-g,  Germany,  a special  laborer  in  this  field,  made 
known  the  result  of  his  investigations,  also  holding  the  view  that  pathological  con- 
ditions of  the  nasal  mucous  membrane  play  the  most  important  part  in  the  production 
of  the  disease.  The  investigations  of  other  observers  substantially  affirm  the  same 
theory.  In  reference  to  my  own  personal  experience,  I will  simply  say,  that  of  the 
thirteen  cases  that  have  come  under  my  personal  observation,  in  each  one  of  them  has 
disease  of  the  nose  or  naso-pharynx  existed.  The  numerous  exciting  and  extrinsic 
causes  which  have  been  supposed  to  bring  on  attacks  of  hay  fever  would  occupy  several 
pages,  and  I will  therefore  simply  refer  to  a few  of  the  more  prominent.  In  those  cases 
where  local  irritability  or  any  deviation  from  the  normal  condition  of  the  nasal  cavities 
exists,  an  attack  may  be  brought  on  by  almost  any  exciting  agent,  an  odor  or  vapor, 
dust,  light  or  heat,  the  pollen  of  flowers  or  grasses.  In  some  cases  I have  known 
the  attack  to  date  from  a severe  cold.  In  support  of  the  view  that  almost  any  agent 
may  produce  a paroxysm,  I will  mention  the  case  of  a patient  who  is  so  susceptible  to 
the  influence  of  ipecac  and  Dover’s  Powder  as  to  be  able  to  produce  an  attack  at  any 
time  by  their  inhalation.  More  recently  the  case  of  a young  man,  a miller  by  profes- 
sion, has  come  under  my  observation,  in  [whom  the  paroxysms  are  produced  by  the 
inhalation  of  small  particles  of  flour  while  following  his  occupation.  During  the  past 
few  years  great  advances  have  been  made  in  bringing  the  treatment  of  hay  fever  within 
the  radius  of  a more  scientific  standpoint,  based  upon  a nearer  approach  to  a rational 
pathology  of  the  disease.  Based  upon  my  own  investigations,  as  already  stated,  I am 
compelled  to  adopt  the  view  that  in  each  case  of  hay  fever  does  a condition  of  the  nasal 
or  naso-pharyngeal  cavities  exist  varying  from  the  normal.  When  we  view  these  facts 
and  theories  with  a view  of  carrying  out  a rational  plan  of  treatment,  we  should  in 
every  case  make  a thorough  anterior  and  posterior  rhinoscopic  examination.  In  a great 
majority  of  cases  a chronic  nasal  catarrh  exists,  with  sensitive  areas  not  confined  to  any 
particular  portion  of  the  mucous  membrane.  In  other  cases  I find  a true  hypertrophic 
condition  either  anterior  or  posterior,  or  both.  Polypi  or  deflections  of  the  nasal 
septum  may  also  act  as  a prominent  factor  in  the  propagation  of  the  disease.  Fully 
believing  that  hay  fever  is  due  to  local  irritatives  brought  in  contact  with  a diseased  con- 
dition of  the  nasal  mucous  membrane,  I am  therefore  compelled  to  call  attention  to  the 
radical  treatment  as  the  chief  mode  of  relieving  or  curing  the  disease.  This  plan  in 
the  hands  of  Daly,  Roe  and  others,  beside  myself,  has  been  followed  by  the  most 


SECTION  XIII — LARYNGOLOGY. 


13 


lasting  and  signal  success.  When  nasal  polypi  exist  I remove  them  by  means  of  Allen’s 
nasal  polypus  forceps  or  Jarvis’  snare,  always  making  sure  to  thoroughly  cauterize  the 
base  with  the  galvano-eautery  or  glacial  acetic  acid.  If  large  hypertrophies,  either 
anterior  or  posterior,  are  found,  they  should  be  removed  by  means  of  the  Jarvis  snare. 
Smaller  hypertrophies  and  sensitive  areas  I destroy  by  using  the  galvano-eautery,  chromic 
acid  or  glacial  acetic  acid,  giving  preference  in  the  order  named.  All  surgeons  have 
favorite  instruments  and  appliances,  giving  preference  to  some,  while  discarding  others. 
The  battery  in  use  by  me  now  for  several  years  was  devised  by  Dr.  Seiler,  of  Philadel- 
phia, and  fulfills  every  indication  required  by  the  operator.  The  current  cau  be  controlled 
by  the  foot  of  the  operator,  thus  giving  him  the  use  of  both  hands,  and  the  temperature 
of  the  knife  can  be  regulated  to  any  degree  of  intensity.  In  using  the  galvano-eautery 
I introduce  an  Allen’s  hard-rubber  nasal  speculum,  through  which  the  electrode  is 
placed  on  the  spot  to  be  cauterized,  after  which  it  is  brought  to  a cherry-red  heat;  great 
care  must  be  taken  to  have  the  electrode  at  the  proper  temperature  when  applied  to  the 
tissue  about  to  be  destroyed,  as,  when  too  hot,  free  hemorrhage  may  result,  and  when 
too  cold  great  pain  will  be  produced.  As  a certain  amount  of  inflammation  is  necessa- 
rily produced,  not  too  large  an  incision  should  be  made  at  any  oue  sitting.  My  prefer- 
ence is  given  to  the  galvano-eautery,  since  it  can  be  brought  more  fully  under  the  con- 
trol of  the  operator  than  chromic  acid,  aud  is  less  painful  than  glacial  acetic  acid.  The 
pain  produced,  as  a rule,  is  but  momentary,  except  occasionally  in  persons  of  a highly 
nervous  organization,  when  I apply  a four  per  cent,  solution  of  hydrochlorate  of 
cocaine,  either  by  means  of  the  atomizer  or  an  aluminium  probe  enveloped  in  cotton. 
The  operation  should  be  repeated  about  once  a week,  or  as  often  as  admissible,  being 
governed  by  the  degrees  of  inflammation  produced,  until  all  hypertrophies  and  sensitive 
spots  are  destroyed.  During  the  intervals  of  the  operations  the  patient  is  directed  to 
use  an  insufflation,  such  as  Dobell’s,  or  some  other  alkaline  solution.  In  the  application 
of  chromic  or  acetic  acid  I use  the  Bosworth’s  application.  The  treatment  should  be 
commenced  about  two  months  before  tbe  accession  of  the  attack,  and  the  nasal  cavities 
should  be  restored  to  as  nearly  a normal  condition  as  possible,  relieving  them  of  all 
hypertrophic  conditions  and  sensitive  areas.  While  I am  of  the  opinion  that  treatment 
should  be  commenced  several  weeks  prior  to  the  expected  attack,  yet  in  no  case  do  I 
desist  from  operating  even  when  the  disease  is  at  its  height.  Iu  several  such  cases  have 
I known  the  intensity  and  duration  of  the  paroxysms  to  be  shortened.  Of  the  thirteen 
cases  upon  which  my  observations  are  based,  nine  have  been  practically  cured,  and  four, 
in  whom  the  treatment  could  not  be  carried  out  perfectly,  were  greatly  benefited.  In 
conclusion,  permit  me  to  say,  that  I have  tried  to  outline,  in  as  brief  a manner  as  pos- 
sible, the  essential  points  of  this  method  of  treatment,  but,  as  will  be  observed,  much 
pertaining  to  the  minor  details  has  been  necessarily  omitted  which  is  essential  to  a proper 
understanding  of  tbe  subject. 

DISCUSSION. 

Mr.  Lennox  Browne,  of  London,  Eng.,  expressed  his  general  assent  with  the 
views  expressed  by  the  authors  of  the  papers,  and  made  a few  rdmarks  on  details. 
He  remarked  the  papers  contained  nothing  new.  He  considered  in  some  cases  the 
pollen  an  exciting  cause,  in  others  the  sole  cause;  the  former  generally  held.  He 
thought  that  often  good  might  he  done  by  gentle  methods,  as  vaseline  protection, 
etc.  Cocaine,  if  long  continued,  might  prove  injurious.  In  using  the  galvano-eautery 
a dull-red  heat  is  best,  and  least  likely  to  produce  hemorrhage. 

Prof.  E.  Eletciier  Ingals,  of  Chicago,  thought  nothing  more  could  be  said 
upon  the  two  papers  than  had  already  been  said  by  Mr.  Lennox  Browne,  but  he  was 
interested  in  what  the  last  speaker  had  said  regarding  the  heat  of  the  electrode.  He 
thought  if  the  naris  was  first  treated  with  vaseline  or  fluid  cosmoline,  it  made  little 


14 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


difference  whether  a red  heat  or  a white  heat  were  employed,  provided  the  electric 
currents  were  not  cut  off  before  the  electrode  was  removed  from  the  tissues,  except- 
ing in  cases  of  deep  incisions,  in  which  hemorrhage  was  very  likely  to  follow  the  use 
of  an  electrode  at  a white  heat. 

Prof.  W.  E.  Casselberry,  of  Chicago,  said — I am  convinced  that  hay  fever  is 
primarily  occasioned  by  local  pathological  lesions  within  the  nose  or  naso-pharynx 
being  acted  upon  by  an  irritant.  It  follows  that  thorough  removal  of  the  pathological 
condition  will  radically  cure  the  disease,  but  it  is  essential  that  its  cauterization  be 
thorough,  that  all  sensitive  or  diseased  areas  be  removed.  Many  having  been  but 
partially  treated  and  but  partially  or  not  at  all  relieved,  speak  adversely  of  the 
method,  and  unfairly  so.  Since  the  cautery  cannot  be  applied  oftener  than  once  a 
week,  to  operate  thoroughly  requires  not  two  months,  the  time  mentioned,  but  often 
four,  five,  six  or  even  more  months;  and  it  should  be  thoroughly  understood  with 
the  patient,  when  treatment  is  commenced,  that  it  is  to  be  carried  to  a finish. 

Dr.  Stucky,  of  Lexington,  Ky.,  thinks  the  majority  of  cases  require  gen- 
eral treatment.  He  summarizes  as  follows  : In  thirty-four  cases  the  majority  were 
neurasthenic,  and  required  constitutional  treatment.  He  never  uses  the  galvano- 
cautery  at  white  heat;  has  better  results  from  dull  red.  If  the  sensitive  area  is  hyper- 
trophied tissue,  he  uses  chromic  acid.  He  usually  prefers  glacial  acetic  acid,  applied 
eveiy  second  or  third  day,  and  destroys  every  sensitive  area,  no  matter  how  many  or 
the  location.  His  after  treatment  is  soothing  and  protective,  and  consists  of  daily 
applications  of  vaseline.  Three  months  was  the  longest  time  he  had  to  treat 
a case. 

Dr.  John  N.  Mackenzie,  of  Baltimore,  Md.,  remarked,  in  regard  to  Dr. 
Thomas’  reference  to  the  sensitive  area  located  by  him  some  years  ago,  that  he  now 
maintained  that  the  posterior  end  of  the  inferior  or  turbinated  bones  and  septum 
were  the  sole  spots  from  which  pathological  reflexes  are  obtained.  Pathological 
reflexes  may  be  gotten  from  any  portion  of  the  membrane,  but  the  area  indicated  by 
him  he  believed  to  be  the  most  sensitive.  Dr.  M.  then  related  his  experiments  with 
artificial  flowers,  to  counteract  the  criticism  of  Prof.  Bosworth  and  Dr.  Thomas. 
Gave  a brief  resume  of  his  theory  of  hay  fever  and  allied  affections  and  criticised 
the  various  theories  hitherto  advanced. 

Dr.  J.  Solis-Coiien,  of  Philadelphia,  Pa. , believed  that  much  of  the  difficulty 
in  understanding  hay  fever  was  due  to  too  much  specialism.  Iu  pre-rhinoscopic  days 
the  general  physician  knew  nothing  of  the  condition  of  the  nose,  and  recent  workers 
in  rhinoscopic  fields  seem  to  know  too  little  of  general  medicine.  His  own  opinion 
closely  coincided  with  that  of  tbe  preceding  speaker,  but  he  would  attribute  the  con- 
stitutional conditions  of  the  sympathetic  portion  of  the  nervous  system,  and  the 
resultant  conditions  of  its  vasomotor  terminals  in  the  vessels  of  the  nasal  mucous 
membrane  to  a lack  of  equilibrium  in  the  nervous  strength  of  the  patient.  This  might 
be  due  to  hereditary  conditions  or  to  acquired  ones,  whether  from  deprivations,  from 
excesses  or  from  overwork.  Hence,  given  a patient  in  this  condition,  the  action  of  an 
irritant  to  which  he  is  very  sensitive  will  precipitate  the  attack  of  hay  fever.  If 
neurasthenic,  his  nervous  system  requires  tonic  treatment.  If  neurasthenic,  it  requires 
sedatives.  This  condition  of  system  must  be  treated  for  long  periods  after  the  subsi- 
dence of  an  attack  in  order  to  get  the  patient  into  such  a condition  of  his  nervous 
system  as  would  render  him  less  susceptible  to  the  irritation  when  the  period  for  his 
hay  fever  recurs.  This  might  take  a very  long  time,  and  require  the  hay  fever  sub- 
ject to  be  under  the  observation  of  his  physician  during  the  entire  interval. 


SECTION  XIII — LARYNGOLOGY. 


15 


Dr.  Ridge,  of  Camden,  New  Jersey,  believed,  from  his  own  experience,  that  hay 
fever  was  of  sympathetic  origin. 

Dr.  Yon  Klein,  of  Dayton,  Ohio,  did  not  believe  that  the  nose  suffered  from 
the  constitution,  but  rather  the  constitution  suffered  from  the  nose.  Hay  fever  is 
not  a neurosis. 

Dr.  Mason,  of  Bloomington,  111. , related  his  personal  experience  of  having  his 
hay  fever  renewed  on  a railway  train,  after  a supposed  cold  of  two  years’  duration. 
The  cause  appeared  to  be  smoke  from  the  locomotive.  He  cited  two  cases  in  which 
it  was  undoubtedly  caused  by  mental  impressions — one  in  which  a child  suffered 
by  imitation  of  her  father’s  symptoms  during  several  years,  to  be  relieved  when  her 
father  was  cured;  in  the  other  case,  a physician  had  aggravated  symptoms  of  hay 
fever  after  hearing  a paper  read  on  the  subject.  Coughs  are  often  produced  by 
hypergestheuic  areas  in  the  naso-pharynx,  which  may  be  cured  by  using  glacial  acetic 
acid. 

Dr.  Frank  0.  Stockton,  of  Chicago,  111. , remarked — To  my  mind  the  causes 
of  so-called  hay  fever  are  three;  namely,  constitutional,  local  and  external;  and  the 
fault  with  gentlemen  who  follow  this  specialty  is  that  they  seek  to  find  one  cause 
alone  for  this  disease. 

Dr.  S.  S.  Koser,  of  Williamsport,  Pa. , objects  to  the  theory  of  the  neurotic 
origin  of  the  disease,  from  the  fact  that  many  of  these  people  are  attacked  on 
a given  day  of  the  month  in  every  year,  and  to  conclude  it  is  entirely  constitutional 
is,  to  my  mind,  illogical.  I know  a lake  far  up  in  the  Alleghanies  to  which  persons 
resorted  with  perfect  immunity  until  this  year,  and  during  this  season  they  have 
suffered,  though  always  heretofore  they  escaped. 

Dr.  R.  H.  Thomas,  in  closing  the  discussion,  said  that  his  object  in  preparing 
his  paper  had  been  largely  to  show  that  the  theories  which  bring  forward  neurasthenia, 
or  nasal  obstruction,  or  the  existence  in  the  healthy  upper  air  passages  of  areas  of 
special  sensation  whose  irritation  would  produce  such  reflex  phenomena  as  asthma, 
etc. , were  not  supported  by  clinical  facts.  He  was  surprised  to  hear  it  asserted  that 
only  two  views  existed  as  to  the  aetiology  of  hay  fever;  the  view  she  had  referred  to 
were  all  held,  and,  in  fact,  the  discussion  which  was  now  closing  had  of  itself  been 
sufficient  to  bring  out  a great  variety  of  opinion  on  the  subject.  His  assertion  that 
the  occurrence  of  an  attack  of  hay  fever  in  a patient  who  had  previously  suffered 
from  the  disease,  by  the  sight  of  an  artificial  rose,  had  no  bearing  on  the  power  of  a 
real  rose  to  produce  an  attack,  had  been  called  in  question.  He  thought  his  posi- 
tion a sound  one.  The  instance  merely  proved  the  power  of  imagination.  He  had 
read  of  cases  where  individuals  supposed  to  be  very  ill  of  hydrophobia  had  recovered 
at  once  on  being  told  the  dog  that  had  bitten  them  was  not  rabid.  All  the  symp- 
toms in  such  cases  were  due  to  imagination,  yet  few  doubted  the  existence  of 
•genuine  hydrophobia.  One  of  the  gentlemen  who  had  taken  part  in  the  discussion 
had  spoken  as  if  the  results  obtained  by  him  (Dr.  Thomas)  in  endeavoring  to  locate 
the  sensitive  areas  had  been  carried  out  during  the  hay  fever  season,  when  all  parts 
of  the  nasal  passages  were  hypersensitive. 

The  paper  had  distinctly  said  that  the  observations  had  been  exclusively  carried 
on  between  the  seasons.  The  result  of  these  observations,  as  far  as  they  had  gone, 
told  against  the  theories  that  were  based  on  the  special  sensitiveness  of  any  particular 
parts  of  the  naso-pharyngeal  tract. 

In  regard  to  the  use  of  the  term  ‘ ‘ idiosyncrasy,  ’ ’ he  did  not  consider  that  the 


* 


16 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


present  state  of  our  knowledge  rendered  it  possible  for  us  to  drop  the  term,  or  some 
equivalent  of  it. 

He  strongly  endorsed  what  had  been  said  as  to  the  importance  of  constitutional 
as  well  as  local  treatment,  and  the  necessity  for  a prolonged  and  thorough  course  in 
order  to  accomplish  satisfactory  results. 


Dr.  D.  N.  Rankin,  of  Allegheny,  Pa. , read  a paper  entitled — 

SOME  REMARKS  OK  THE  HISTORY  OF  RHINOLOGY. 

QUELQUES  REMARQUES  SUR  L’HISTOIRE  DE  LA  RIIINOLOGIE. 

EINIGE  BEMERKUNGEN  UBER  DIE  GESCHICHTE  DER  RHINOLOGIE. 

BY  D.  N.  RANKIN,  A.M.,  M.D., 

Allegheny,  Pa. 

Until  a comparatively  recent  date  the  nasal  cavities  have  been  sadly  neglected. 
This  neglect  is  more  surprising  in  face  of  the  fact  that  the  nares  furnish  the  natural 
medium  for  respiration;  that  they  are  the  organ  of  smell,  thereby  protecting  the  lungs 
from  the  inhalations  of  deleterious  gases,  and  assisting  the  organ  of  taste  in  discrimi- 
nating the  properties  of  food  ; and  as  an  adjunct  to  the  vocal  apparatus  in  making  a 
pleasant  voice,  they  are  indispensable. 

It  is  certainly  very  desirable  to  have  an  acute  sense  of  smell,  though  it  is  not  so 
important  as  some  of  the  other  senses. 

Of  its  pleasures,  let  me  here  mention  a few:  Every  hill,  and  vale,  and  shore  is  trib- 
utary to  the  sense  of  smell.  There  appears  to  he  a scale  in  odors  with  respect  to  the 
pleasures  which  they  excite  in  the  organ  of  smell.  The  rose  appears  to  be  at  the  head 
of  this  scale,  the  shrub  next,  the  pink,  the  jessamine,  the  tuberose,  the  honeysuckle, 
the  sweetbriar,  all  gradually  descend  from  it.  The  pleasure  derived  from  odors  is  much 
increased  by  mixture.  There  can  be  little  doubt  that  these  odors  are  so  related  to  each 
other  as  to  produce  from  different  mixtures  greater  or  less  degrees  of  harmony  analo- 
gous to  the  vibrations  of  musical  sounds. 

The  odor  of  flowers,  certain  vegetables,  and  meats  in  the  process  of  cooking,  is  not 
only  pleasant,  but  nutritious  and  medicinal,  from  the  stimulus  it  imparts  to  the  whole 
system  through  the  medium  of  the  sense  of  smelling.  Country  air  owes  one  of  its 
beneficial  effects  on  invalids  to  this  cause. 

The  sense  of  smell  is  liable  to  be  perverted,  as  we  see  in  the  artificial  pleasure  which 
some  people  derive  from  the  fetor  of  the  civet,  musk,  asafoetida,  and  even  of  the  snuff 
of  a candle. 

Who  that  never  saw  or  experienced  it,  would  believe  that  the  odor  of  the  rose 
could  produce  fainting,  or  that  the  heliotrope  and  the  tuberose  have  made  some  persons 
asthmatical.  The  smell  of  musk,  so  grateful  to  many  people,  sickens  some. 

It  is  well  known  that  the  sense  of  smell  guides  many  of  the  lower  animals  to  their 
food,  or  warns  them  of  danger,  as  is  exemplified  in  the  hunting  dog.  The  distance  at 
which  a dog  tracks  his  master  is  scarcely  credible. 

The  acuteness  of  the  sense  of  smelling  in  animals  is  such  that  in  many  instances 
our  observations  have  been  deemed  fabulous.  Birds  of  prey  will  scent  the  battle  field 


SECTION  XIII — LARYNGOLOGY. 


17 


at  prodigious  distances,  and  they  are  often  seen  hovering  instinctively  over  the  ground 
where  the  conflict  is  to  supply  their  festival. 

Ancient  historians  assert  that  vultures  have  cleft  the  air  one  hundred  and  fifty 
leagues  to  arrive  in  time  to  feast  upon  a battle  field. 

Whence  comes  it  that  the  red-wing,  that  passes  the  summer  in  Norway,  or  the  wild 
duck,  that  summers  in  the  woods  and  lakes  of  Lapland,  is  able  to  track  the  pathless 
void  of  the  atmosphere  with  the  utmost  nicety,  and  arrive  on  our  own  southern  coasts 
uniformly  in  the  beginning  of  October. 

It  has  been  observed  that  animals  which  possess  the  most  acute  smell  have  the 
nasal  organs  the  most  extensively  developed.  The  American  Indians  are  remarkable 
for  the  acuteness  of  this  sense,  which  accounts  for  their  wonderful  power  of  tracking 
their  enemies. 

By  a glance  over  the  text-books,  you  will  find  in  the  chapter  on  nasal  diseases  that 
they  do  not  receive  that  attention  they  deserve.  It  is  an  undeniable  fact,  that  perhaps 
no  department  of  medicine  has  been  so  much  invaded  by  quacks.  It  is  true  they  often 
acquire  reputation  and  wealth,  but  this  must  be  ascribed  to  the  credulity  of  their 
patients,  and  to  the  zeal  with  which  they  exaggerate  and  advertise  their  cures,  or 
palliate  or  deny  their  mistakes. 

It  has  been  said,  and  well  said,  that  quacks  are  the  greatest  liars  in  the  world,  except 
their  patients.  “ Quacks  and  impostors,”  said  Lord  Bacon,  “ have  always  held  a com- 
petition with  physicians.” 

Galen  observed  that  patients  placed  more  confidence  in  the  oracles  of  Esculapius 
and  their  own  idle  dreams,  than  in  the  prescriptions  of  doctors. 

No  science  has  been  cultivated  with  more  difficulty  than  that  of  this  specialty.  Sir 
Astley  Cooper  used  to  complain  that  a knowledge  of  the  nasal  cavities  is  by  no  means 
general  in  the  profession,  and  still  less  are  their  diseases  understood. 

Compare  the  armamentarium  of  thirty  years  ago  with  the  outfit  of  the  nasal  special- 
ist of  to  day.  What  was  it  previous  to  thirty  years  ago  ? Literally  nothing  ; no  perfect 
rhinoscope,  no  insufflator,  no  inhalers,  no  galvano-cautery,  no  incandescent  light,  no 
sponge  holders,  no  guillotine,  no  ecraseur,  no  snares.  A single  pair  of  polypus  forceps  and  a 
cumbersome  nose  speculum  constituted  the  set.  While  visiting  the  mountainous  districts 
of  western  Pennsylvania,  some  years  ago,  I went  into  the  office  of  the  village  doctor  to 

I pay  my  respects.  He  was  a man  of  perhaps  seventy  years  of  age.  In  conversation  I inquired 
if  he  had  much  nose  and  throat  disease  to  treat.  He  said  he  had  considerable  of  that 
class  of  disease  to  look  after.  He  then  exhibited  his  nose  and  throat  instruments,  which 
consisted  of  a tongue  depressor  and  polypus  forceps.  He  informed  me  that  the  tongue 
depressor  was  made  by  the  village  blacksmith.  Our  forefathers  depended  principally 
upon  general  treatment  and  snuffs,  as  then  treatment  locally  was  not  thought  of.  If  a 
person  was  unfortunate  enough  to  have  any  of  the  many  forms  of  disease  of  the  nasal 
cavities,  it  was  allowed  to  progress  uninterruptedly,  short  of  a constitutional  treatment. 

It  appears  from  historical  accounts  that  the  ancients,  especially  the  Egyptians,  made 
rhinoscopic  examinations,  but  with  what  success  is  not  stated.  Since  Prof.  Czermak, 
of  Pesth,  conceived  the  idea  of,  and  introduced  to  the  attention  of  the  profession,  the 
rhinoscope,  wonderful  indeed  has  been  its  utility  in  diagnosing  affections  of  the  nares 
which  previously  had  been  very  unsatisfactory  and  obscure.  The  usefulness  of  the 
rhinoscope,  however,  would  have  been  greatly  lessened  had  it  not  been  for  the  ingenuity 
of  other  eminent  rhinoscopists,  who  have  devised  many  useful  surgical  instruments  as 
well  as  means  for  making  therapeutical  and  electrical  applications  to  the  nasal  cavities, 
whereby  local  applications  can  as  readily  be  made  to  the  posterior  nares  as  to  the 
pharynx.  Czermak  has  done  for  the  nasal  organs  what  the  illustrious  Laennec  has 
done  for  the  organs  of  respiration. 

The  therapeutics  of  the  nares  have  kept  pace  with  the  surgical  and  electrical  pro- 
Vol.  IV— 2 


18 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


cedures  of  that  organ.  Among  the  many  excellent  remedies  that  have  been  locally 
utilized,  I would  merely  mention  four — iodoform,  bismuth,  chromic  acid  and  cocaine. 

The  general  practitioner,  when  summoned  to  see  a case  of  nasal  disease,  is  too  often 
satisfied  with  a too  superficial  examination.  Generally,  he  raises  the  point  of  the  nose 
somewhat,  and  then  the  vague  pronunciations  are  uttered  : “ high  up  in  the  nares,”  or 
“ deep  down  in  the  nares,”  or,  in  the  case  of  a child,  ‘‘let  it  alone,  it  will  grow  out  of 
it.”  Therefore,  it  cannot  be  wondered  at  that  the  diagnosis  and  treatment  of  nasal 
diseases  have  been  in  a mixed  condition. 

We  live,  gentlemen,  in  a revolutionary  age;  our  science  has  caught  the  spirit  of  the 
times,  and  more  improvements  have  been  made  in  this  specialty  within  the  past  twenty- 
five  years  than  had  been  made  in  a century  before.  From  these  events,  so  auspicious  to 
our  department,  we  may  cherish  a hope  that  advancement  may  draw  nearer  perfection. 

Great  Britain  is  entitled  to  a large  share  of  the  influence  in  the  advancement  of  this 
specialty.  It  has  contributed  much  to  this  movement  by  careful  clinical  observations 
of  diseases  of  the  nose,  and  by  numerous  contributions  to  our  anatomical  and  physio- 
logical knowledge  of  nasal  diseases.  The  German  spirit,  recognizing  the  importance  of 
this  new  era,  joined  in,  hand  in  hand.  Austria,  Denmark,  Russia,  France,  Spain  and 
Italy  are  all  well  represented  by  men  eminent  in  this  specialty. 

America,  never  behind  in  anything  that  conduces  to  the  benefit  of  mankind,  is  rep- 
resented by  men  of  marked  ability  as  writers  and  teachers,  as  well  as  successful  practi- 
tioners in  this  department. 

The  American  Laryngological  Association  and  the  American  Rhinological  Associa- 
tion are  institutions  we  feel  proud  of.  The  former,  with  a fellowship  of  over  fifty 
members,  is  composed  of  the  very  best  talent  in  this  country,  who  have  already  made 
their  mark,  and  are  still  actively  engaged  in  prosecuting  their  valuable  labors.  The 
American  Rhinological  Association,  being  of  recent  origin,  is  composed  of  excellent 
material  and  doing  good  work.  It  was  my  good  fortune,  during  the  last  meeting  of  the 
International  Medical  Congress  at  Copenhagen,  Denmark,  to  meet  most  of  the  gentle- 
men of  the  Laryngological  Section,  and  without  a single  exception  those  I met  were 
persons  of  the  highest  medical  attainments,  and  gentlemen  in  every  sense  of  the  word. 

Here  permit  me  to  say  a word  in  memory  of  the  father  of  Rhinology  and  Laryn- 
gology in  America.  I refer  to  the  late  Lewis  Elsberg,  a man  whose  memory  we  should 
all  revere,  as  not  only  a gentleman  and  scholar,  but  most  eminent  in  Rhinology  and 
Laryngology.  He  unquestionably  did  much  to  advance  these  specialties. 

To  America  is  due  the  credit  of  bringing  rhinology  to  its  present  status.  Dr.  Daly 
has  doubtless  done  more  to  accomplish  this  end  than  any  man  in  this  country. 

The  ample  means  we  now  possess  of  investigating  diseases  of  the  nares,  and  the 
facility  with  which  the  true  nature  of  these  diseases  is  arrived  at,  is  certainly  very 
encouraging. 

Comparing  rhinology  to  a house,  the  different  stories  of  which  have  been  erected  by 
different  architects,  Czermak,  Elsberg,  etc.,  have  a large  claim  to  our  gratitude  for 
having,  by  their  arduous  and  successful  labors,  advanced  the  building  to  its  present 
height.  It  belongs  to  the  rhinologists  of  the  present  and  future  generations  to  place  a 
roof  upon  it,  and  thereby  complete  the  fabric  of  rhinology. 


DISCUSSION. 

Dr.  M.  F.  Coomes,  of  Louisville,  Ky.,  remarked:  In  1859,  Dr.  Troupe  Max- 
well, of  Kentucky,  had  a mirror  constructed,  and  obtained  a view  of  the  vocal  cords, 
not  the  posterior  nares.  He  was  certainly  the  first  American  to  use  a mirror  for 
looking  at  the  vocal  cords. 


SECTION  XIII — LARYNGOLOGY. 


19 


SECOND  DAY. 


The  Section  was  called  to  order  at  11  A.  M.,  the  President  in  the  chair. 

Mr.  Lennox  Browne,  of  London,  read  a paper  entitled — 

RECENT  VIEWS  ON  THE  PATHOLOGY  AND  TREATMENT  OF  TUBER- 
CULOSIS OF  THE  THROAT  AND  LARYNX. 

APERfU  RECENT  SUR  LA  PATHOLOGIE  ET  TRAITEMENT  DE  LA  TUBERCULOSE 

DE  LA  GORGE  ET  DU  LARYNX. 

NEUE  ANSICHTEN  UBER  DIE  PATHOLOGIE  UND  BEHANDLUNG  DER  TUBERKULOSE  DES 

SCHLUNDES  UND  XEHLKOPFES. 


BY  MR.  LENNOX  BROWNE,  F.  R.  C.  S. , EDIN. , 

London. 

At  the  present  time  it  is  almost  universally  accepted  that  the  tuberculous  process  is 
initiated  by  the  settlement  of  a specific  bacillus  on  a suitable  nidus,  or,  as  it  was  form- 
erly called,  at  the  spot  of  least  resistance.  This  bacillus  is  of  the  nature  of  a fungus, 
and  partakes  of  the  special  characteristic  of  all  fungi,  in  that  it  requires  for  its  growth  a 
soil  in  which  organic  decay  is  taking  place.  Bacilli  gain  access  to  the  lungs  by  means, 
primarily,  of  the  main  air  passages;  they  may  he  deposited  at  a portion  of  the  lung, 
for  example,  an  apex,  which  is  ill  supplied  with  blood  and  especially  with  air,  or  in 
the  altered  pulmonary  tissue  which  invariably  exists  after  an  acute  lung  disease ; of 
this  we  see  an  example  in  the  case  of  tuberculosis  following  basal  pneumonia. 

Like  all  parasites,  bacilli  are  highly  irritating,  expression  of  which  quality  is  evi- 
denced in  the  formation  of  the  miliary  tubercle,  a tissue  of  very  low  vitality,  prone  to 
break  down.  As  to  whether  the  bacilli  reach  the  tissue  through  a break  of  epithelial 
continuity,  by  diapedesis  or  otherwise,  is  a question  which  cannot  now  be  entered  on. 
What  we  do  know  is  that  the  bacilli,  having  once  established  themselves,  multiply  in 
large  numbers,  and  this  circumstance  leads  not  only  to  a local  increase  in  the  morbid 
process,  but  also  to  access  of  bacilli  to  the  general  circulation  by  the  lymphatic  system. 
When  the  tubercles  are  broken  down  so  as  to  form  cavities,  bacilli  are  more  or  less 
abundant  in  the  sputa.  It  is  thus  evident  that  bacilli  may  arrive  at  the  region  of  the 
larynx  by  at  least  two  routes. 

Taking  into  account  the  fact  that  tuberculous  infiltration  usually  invades  the  deeper 
tissues  of  the  larynx  at  an  early  period  of  the  disease,  and  before  any  breach  of  con- 
tinuity of  surface,  I am  inclined  to  the  conclusion  that  when  laryngeal  phthisis  follows 
a pulmonary  disease  of  the  same  nature,  the  tubercles  are  transplanted  through  the 
systemic  circulation.  Without  doubt,  however,  it  occasionally  happens  that  there  is 
direct  infection  by  the  sputa  through  a breach  of  surface,  the  result  of  a coincident 
catarrhal  laryngitis  more  or  less  acute.  But,  as  a general  rule,  there  must  be  in  the 
larynx,  as  in  the  lungs,  a condition  of  local  receptivity.  One  factor,  at  least,  of  this 
predisponent  is  that  of  anajmia.  This  is  manifested  preferably  at  marginal  and  apical 


20 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


regions  of  the  larynx,  as  of  the  lungs,  and  we  thus  find  that  the  general  seats  of  earliest 
infiltration  are  the  inter-arytenoid  space,  the  coverings  of  one  or  both  of  the  arytenoid 
cartilages,  the  ary-epiglottic  folds  and  the  epiglottis.  On  the  other  hand,  in  those 
cases  in  which  functional  abuse  is  an  exciting  cause  of  the  local  process,  the  tumefaction 
may  first  occur  in  the  vocal  cords  and  the  ventricular  bands.  In  this  last  class  of  cases, 
and  in  some  few  others  not  due  to  functional  causes,  the  first  condition  is  one  of  per- 
sistent hypenemia  instead  of  anaemia,  and  instances  will  occur  to  every  practitioner 
illustrative,  in  its  special  application  to  the  throat,  of  Trousseau’s  dictum,  that  a 
neglected  catarrh  is  often  a consumption  commenced.  There  is,  in  fact,  a condition  of 
the  larynx  predisposing  to  tuberculous  deposit  very  analogous  to  that  of  an  unresolved 
pneumonia. 

Ulcerations  of  laryngeal  phthisis  are  characterized  by  their  small  size,  their  mul- 
tiple character,  and  their  tendency  to  coalesce  and  to  extend  laterally  rather  than  to 
penetrate  deeply.  As  before  mentioned,  erosions  non-tuberculous  in  character  may 
appear  in  the  larynx  of  a tuberculous  patient  the  subject  of  a fortuitous  catarrh.  Doubt- 
less, some  of  those  that  heal  under  treatment  are  of  this  nature.  It  remains  to  say  a 
few  words  as  to  the  mode  of  origin  of  tuberculous  manifestations  in  the  fauces.  A 
long  experience  has  assured  me  that  disorders  of  absorption,  assimilation,  and  digestion 
generally  play  a far  more  important  part  in  the  production  of  faucial,  tonsillar  and 
pharyngeal  inflammations  than  any  faults  of  atmosphere,  climate  or  even  exposure  to 
cold  and  damp,  these  last  preferably  and  mainly  affecting  the  respiratory  tracts.  When 
the  pharynx  is  attacked  in  the  case  of  an  advanced  pulmonary  or  laryngeal  phthisis, 
we  may  not  presuppose  a breach  of  surface  to  be  absolutely  necessary  for  infection  of 
this  region  by  bacilli  contained  in  the  sputa  and  oral  fluids,  but  we  may  postulate  that 
the  absorption  of  the  liquid  portions  of  the  contaminated  oral  secretions  must  lower  the 
vitality  of  the  faucial  and  pharyngeal  mucous  membrane;  in  fact,  a nidus  is  formed  for 
the  settlement  of  bacilli  brought  thither  by  the  general  circulation.  When  the  fauces 
are  primarily  attacked  we  must  admit  the  probability  of  a previous  breach  of  continuity. 
I have  reported  a case  in  which  the  local  irritation  of  diseased  teeth,  as  evinced  by 
marked  improvement  following  their  extraction,  was  the  exciting  cause  of  a tuberculous 
ulceration  of  the  gums  and  mouth. 

In  my  experience,  evidence  of  the  tuberculous  process  is  manifested  later  in  the 
fauces  than  in  the  larynx,  but,  as  I could  show  by  relation  of  many  cases,  this  region 
may  be  attacked  at  any  stage  of  the  disease;  several  circumstances,  especially  the  now 
well  known  case  of  Demme*,  have  confirmed  the  opinion  long  entertained,  though 
until  recently  unsubstantiated,  that  laryngeal  phthisis  may  precede  the  pulmonary 
disease,  | and  it  is  quite  possible  that  similar  evidence  will  be  afforded  regarding  the 
fauces  and  pharynx.  At  present  we  are  not  in  a position  to  do  more  than  assume  its 
probability. 

Some  six  and  a half  years  ago  I reported,  in  conjunction  with  Dundas  Grant,  two 
cases — one  arising,  as  just  recorded,  from  direct  irritation  of  decayed  teeth,  in  which 
the  first  manifestation  in  the  mouth  and  fauces  had  occurred  between  two  and  three 
years  previously  to  any  chest  attack,  or  even  before  the  suspicion  of  pulmonary  disease. 

Last  December  I exhibited  a patient  at  the  Medical  Society  of  London,  and  I have 


* Demme’s  case  is  that  of  a boy  aged  four  and  a half  years,  who  died  of  tubercular  menin- 
gitis; the  neoropsy  showed  the  prosonco  of  laryngeal  ulceration  with  tubercle  bacilli;  the  thoracic 
and  abdominal  organs  being  at  the  same  time  free  from  tubercular  disease. 

•j-  Zichl  has  also  related  a very  pertinent  example,  in  which  a woman  was  tracheotomized  for 
laryngeal  stenosis.  The  pulmonary  secretions,  which  could  thus  be  perfectly  separated  from  those 
of  the  larynx,  were  free  of  bacilli,  while  those  taken  directly  from  the  laryngeal  ulceration  con- 
tained them. 


SECTION  XIII — LARYNGOLOGY. 


21 


reported  it  in  full  in  the  recently  published  second  edition  of  my  work,  “The  Throat 
and  its  Diseases;”  as  far  as  clinical  evidence  could  go,  it  clearly  establishes  the  proba- 
bility of  a primary  tuberculous  ulceration  in  the  upper  throat. 

The  subject  was  a young  woman,  aged  twenty,  the  mother  of  three  children,  the 
youngest  of  whom  was  fourteen  months  old.  She  applied  for  treatment  on  account  of 
extreme  pain  in  swallowing,  not  only  food,  but  even  saliva.  There  was  no  distress  of 
breathing,  no  night  sweats  nor  diarrhcea.  Physically  there  was  seen  to  be  ulceration 
of  the  left  tonsil  and  of  the  back  wall  of  the  pharynx  along  its  whole  length,  with 
slight  extension  to  the  posterior  border  of  the  larynx.  Beyond  very  moderate  conges- 
tion of  the  coverings  of  the  arytenoids,  and  hardly  preceptible  thickening  of  the  inter- 
arytenoid fold,  there  was  no  other  laryngeal  disease,  and  the  stethoscope  revealed 
nothing  beyond  slight  harshness  of  respiration  and  somewhat  impaired  resonance  at  the 
right  apex.  Tubercle  bacilli  were  abundantly  manifested  in  the  sputa.  Under  treat- 
ment— by  scraping  and  lactic  acid — the  patient  lost  all  her  symptoms,  and  beyond  some 
adhesion  of  the  left  posterior  faucial  pillar  there  could  be  detected  no  signs  of  her  former 
disease,  but  whenever  the  saliva  was  examined,  as  was  done  for  many  weeks  after  all 
functional  and  physical  signs  had  disappeared,  tubercle  bacilli  could  be  detected.  It 
may  be  mentioned,  en passant,  that  this  circumstance  well  illustrates  the  limit  of  use- 
fulness of  bacillary  evidence.  It  is  an  important  factor  of  diagnosis  of  the  presence  of 
tubercle,  but  of  uncertain  value  in  prognosis,  since  bacilli  are  often  as  abundant  in  mild 
and  chronic  cases  as  in  those  of  an  acute  and  advanced  character.  However,  a very 
careful  and  thrice  repeated  search  failed  to  detect  any  bacilli  on  the  last  occasion  on 
which  I saw  her,  namely,  one  week  before  I left  England.  The  patient  has  gained  weight 
and  is  really  in  fair  health;  the  lung  symptoms  have  not  in  the  least  degree  advanced 
since  the  first  examination. 

Having  thus  indicated  some  of  the  more  important  of  the  local  pathological  circum- 
stances on  which  we  are  to  base  our  treatment,  and  necessarily  excluding  from  the 
present  discussion  pulmonary  conditions,  let  us  proceed  to  consider  the  means  at  our 
command  for  combating  the  tuberculous  process  in  the  pharynx  and  larynx,  and,  for  the 
sake  of  still  further  confining  my  observations  within  available  limits,  I shall  suppose 
that  we  have  a case  before  us  in  which,  though  the  morbid  process  is  well  established 
in  some  portion  of  the  throat,  the  general  system  has  not  yet  broken  down,  or  the  lung 
disease  advanced  so  far  as  to  preclude  the  hope  of  restoration  to  comparative  health  and 
a prolongation  of  comfortable  and  useful  life. 

The  basis  of  our  treatment  must  be  : First,  by  certain  climatic,  hygienic  and  general 
measures,  to  place  the  patient  in  the  most  favorable  position  for  resisting  the  baneful 
influence  of  the  bacilli,  and,  if  we  can,  of  rendering  their  life  impossible.  Under  this 
head  I have  a preference  for  sea  voyages  and  mountain  air  over  residence  in  very  hot 
climates,  and  especially  at  health  resorts  where  the  air  is  unduly  moist,  though,  of 
course,  such  circumstances  must  be  regulated  by  the  particular  character  and  stage  of 
the  case.  The  advantages  of  sea  air  and  mountain  elevation  are  generally  allowed  to 
arise  from  the  greater  rarity  of  morbific  germs  and  the  larger  amount  of  oxygen  and 
ozone  present  in  such  atmospheres.  The  only  satisfactory  case  of  actual  cure  of  laryn- 
geal phthisis  that  I have  seen  has  been  the  result  of  two  sea  voyages  and  a residence  for 
two  years  in  New  Zealand.  The  subject,  when  first  brought  to  my  notice,  was  a lad 
of  fifteen.  The  nature  of  the  case  was  undoubted,  and  was  confirmed  by  others.  Lung 
disease  was  hardly  to  be  detected.  The  patient  is  now  twenty-two  years  of  age,  and 
a hale  farmer  in  the  west  of  England.  Hunter  Mackenzie,  in  a recent  article,  has 
deprecated  high  altitudes  as  too  irritating  for  patients  suffering  from  throat  consumption, 
but  such  an  objection  does  not  apply  to  the  earlier  stages  or  to  cases  in  which  the  lungs 
are  but  slightly  implicated.  On  the  contrary,  I have  seen  the  happiest  effects  from 


22 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


residence  on  mountainous  plateaus.  There  are,  of  course,  many  circumstances  not 
possible  to  at  present  consider,  which  may  modify  our  advice  on  this  head. 

Supplementary  to  these  climatic  measures  may  be  considered  those  of  inhalation, 
and  I have  only  here  to  state  that  for  some  years  I have  ceased  to  advise  those  of 
medicated  steam.  I cannot  agree  with  a recent  author,  Massei,  that  oro-nasal  inhalers 
have  at  all  fallen  out  of  fashion.  My  daily  experience  convinces  me  more  and  more 
of  their  value.  The  particular  mixture  I employ  for  general  use  is  one  composed  as 
follows : Oil  of  pine  and  oil  of  eucalyptus,  of  each  a drachm  ; alcohol  and  ozonic  ether, 
of  each  eleven  drachms.  I have  also  found  benefit  from  the  inhalation  of  menthol,  as 
advised  by  Rosenberg.  This  remedy  is  particularly  valuable  in  the  stage  of  anaimia 
and  infiltration,  i.  e.,  before  the  occurrence  of  ulcerations.  Under  its  use  I have  seen 
perceptible  and  increasing  improvement  in  the  shape  of  recovery  of  normal  color  of  the 
mucous  membrane  and  diminution  of  submucous  infiltration.  In  the  hyperaemic  type 
I have  witnessed  resolution  by  means  of  the  same  remedy.  The  patients  get  to  like 
the  treatment  so  much  that  there  is  no  necessity  to  encourage  them,  as  is  advisable,  to 
wear  the  inhaler  as  long  as  possible,  both  waking  and  sleeping.  I have  found  the  cheap 
inhaler  of  Squire,  devised  by  Burney  Yeo,  answer  as  well  for  general  hospital  purposes 
as  any  of  the  more  elaborate  apparatus. 

There  is  no  doubt  that  the  tuberculous  process,  when  once  thoroughly  established, 
is  one  of  septicaemia,  and  it  is  probable  that  the  colliquative  sweating  and  diarrhoea, 
the  general  asthenia  and  cardiac  failure,  often  manifested  by  the  phthisical  patient  in 
whom  there  is  no  actual  cardiac  disease,  may  all  be  explained  as  results  of  ptomaine 
poisoning.  Many  of  these  general  symptoms  are  relieved  by  the  oro-nasal  inhaler  ; but 
the  particular  alkaloid  which  seems  antidotal  to  many  of  these  evidences  of  ptomaine 
toxaemia  is  atropine.  In  any  case,  apart  from  theory,  it  is  a symptomatic  remedy  of 
acknowledged  value. 

Of  further  general  measures  I need  only  allude  to  the  hypophosphites,  but  I may 
mention  that  while  I often  employ  them  in  combination,  as  in  Fellows’  svrup,  I have 
a preference  for  the  salt  of  calcium  as  more  likely  to  bring  about  a beneficent  (calca- 
reous) degeneration  of  diseased  tissues.  I have  also  witnessed  the  excellent  results  to 
be  obtained  by  administration  of  small  doses  of  arseniate  of  soda  or  potash.  Arsenic 
appears,  indeed,  to  act  on  the  tuberculous  dyscrasia  much  in  the  same  specific  way — 
though  perhaps  less  powerfully — as  does  mercury  in  syphilis. 

The  second  indication  is  to  annihilate  the  bacilli  by  germicides.  These  remedies 
may  be  divided  into  two  classes — those  which,  while  acting  as  germ  destroyers,  may 
also  powerfully  affect  the  general  system,  and  those  of  a more  purely  local  character. 
Among  the  former  are  to  be  mentioned  perchloride  of  mercury,  aniline,  and  perhaps 
in  a less  degree  sulphureted  hydrogen  and  dioxide  of  carbon. 

Looking  to  the  injurious  effects  of  mercurial  combinations  when  internally  admin- 
istered to  a tuberculous  patient,  I cannot  recommend  either  sprays  or  injections  of  cor- 
rosive sublimate.  My  own  conviction  is,  that  as  germs  are  killed  with  more  difficulty 
than  are  normal  cells,  especially  in  persons  of  tuberculous  tendency,  the  remedy  might 
but  aggravate  the  disease.  Nevertheless,  Massei  states  that  he  has  found  the  effect  so 
satisfactory  that  he  now  employs  it  in  daily  practice  to  the  strength  of  1 in  2000.  The 
aniline  treatment  by  Kremianski  has  had  but  a short  life  and  is  generally  condemned. 

The  sulphureted  hydrogen  treatment,  introduced  by  Bergeon  aud  administered  per 
rectum , is  yet  on  its  trial.  Its  special  office  seems  to  be  to  check  bronchial  secretion 
and  to  diminish  night  sweats,  but  it  is  doubtful  if  the  process  is  in  any  sense  truly 
microbicidal.  I have  no  especial  experience  of  this  remedy  at  present  beyond  one  ease, 
in  which  the  effect  appeared  at  first  to  be  very  favorable — profuse  brouchorrhoea  and 
night  sweats  being  both  arrested  almost  as  by  a charm;  but  on  the  patient  leaving  his 


SECTION  XIII — LARYNGOLOGY. 


23 


physician,  Dr.  Sinclair  Cogliill,  whom  I am  happy  to  see  present,  and  continuing  the 
treatment  himself  without  medical  supervision,  such  alarming  symptoms  of  dyspnoea 
occurred  that  I was  summoned  to  perform  tracheotomy.  The  operation  was,  unhappily, 
of  no  avail,  although  I made  the  opening  as  low  as  possible  in  the  trachea,  we  having 
diagnosed,  prior  to  operation,  that  there  was,  in  addition  to  a mechanical  laryngeal 
stenosis,  a further  considerable  obstruction  of  the  left  bronchus  near  its  bifurcation. 
After  death,  Dr.  Montague  Ball,  of  Hounslow,  who  was  the  practitioner  in  attendance, 
found  that  the  vocal  cords  were  greatly  thickened  and  congested,  the  whole  trachea  and 
bronchi  also  very  much  congested  and  the  left  bronchus  almost  entirely  blocked  by  a 
plug  of  thick,  fibrous  mucus.  There  was  also  great  enlargement,  with  caseation  of 
the  glands  surrounding  the  left  bronchus  to  such  an  extent  as  to  considerably  diminish 
the  diameter  of  the  tube.  In  the  light  afforded  by  the  autopsy,  it  would  be  unreason- 
able to  say  that  the  fatal  result  was  due  to  the  treatment;  nevertheless,  it  should  warn 
us,  in  cases  favorable  for  its  adoption,  against  allowing  a patient  to  undertake  it  himself, 
as  has  been  advised  and  countenanced  by  several  writers  on  the  subject. 

Of  the  germicides  producing  local  effects  may  be  mentioned — 

1.  Galvano-cautery. 

2.  Lactic  acid. 

3.  Menthol. 

4.  Iodoform  or  iodol. 

The  first  I have  employed  with  success  in  tuberculous  ulceration  of  the  tongue  and 
tonsil,  and  I have  reported  cases  in  support  of  its  adoption. 

The  second  has  proved  of  great  service  in  the  practice  of  myself  and  my  colleagues 
in  pharyngeal  and  faucial  manifestations.  It  is  preceded  by  an  application  of  a ten 
per  cent,  solution  of  cocaine  and  a scraping  of  the  surface  to  which  the  acid  is  to  be 
applied.  Its  effect  is  to  stimulate  healthy  reaction,  and,  as  Krause  has  said,  pain  is  no 
contraindication  to  success ; for  on  recovering  from  inflammation,  the  parts  generally 
cicatrize  healthily. 

I have  been  so  satisfied  with  this  treatment  that  I have  not  employed  the  remedy 
by  means  of  the  syringe,  as  was  first  recommended  by  Hering,  of  Warsaw.  Moreover, 
I have  a distinct  preference  for  a cotton-wool  brush  over  the  spray;  for,  as  Roe,  of 
Rochester,  has  shown,  remedies  introduced  by  the  latter  method  do  not  penetrate  to  the 
ventricles  and  other  chinks  and  crannies  of  the  larynx  so  well  as  when  the  sphincter 
glottidis  squeezes  the  fluid  from  a brush.  This  author  believes  that  the  continuous  use 
of  sprays  is  injurious  to  the  cilia  of  the  mucous  membrane  of  the  air  passages,  but  that 
there  is  no  such  danger  in  soft  brushes.  In  this  respect  the  solution  carrier  made  of 
absorbent  wool  possesses  advantages  over  those  of  camel  hair  or  sponge.  Whatever 
form  of  applicator  is  employed,  it  is  important  to  clear  away  the  excess  of  frothy  saliva 
and  other  tenacious  secretion  that  always  overloads  a tuberculous  throat.  Neglect  to 
take  this  precaution  may  account  for  many  instances  of  failure  of  local  treatment.  The 
circumstance  itself  explains  why  fine  sprays  and  insufflations  are  often  inert,  whereas 
the  slight  friction  inseparable  from  the  use  of  the  brush  is  really  beneficial. 

As  to  the  third  method,  our  experience  at  the  Central  London  Throat  and  Ear  Hos- 
pital, of  lactic  acid  in  the  larynx,  has  not  been  so  favorable  as  in  the  upper  throat,  and 
we  have  frequently  employed  menthol,  20  per  cent.,  as  advised  by  Rosenberg.  Although 
at  first  rather  pungent,  its  application  is  quickly  followed  by  a distinctly  anaesthetic 
effect.  1 am  not  sure  that  ulcerations  often  or  ever  heal  under  this  treatment,  but  I 
have  no  doubt  that  infiltration  is  frequently  resolved,  that  in  the  case  of  anaemia  the 
tissues  gain  color,  while,  when  the  condition  is  one  of  congestion,  the  hyperannia  is 
reduced. 

The  fourth  is  that  of  iodoform  or  iodol,  which  it  is  recommended  to  apply  in  either 
ethereal  or  alcoholic  solutions  or  as  insufflations.  These  remedies  have  many  warm 


24 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


advocates  among  practitioners  of  repute,  particularly  of  Lubinski,  but  have  failed  to 
give  satisfaction  in  my  own  practice.  It  is  to  be  noted  that,  according  to  recent  inves- 
tigations, not  only  is  the  germicidal  action  of  this  drug  doubted,  but,  as  Watson  Cheyne 
states,  germs  may  even  be  cultivated  in  its  presence. 

Although  in  no  sense  curative,  insufflations  and  other  remedies  of  a purely  anodyne 
character  demand  at  least  passing  consideration.  For  myself,  I limit  insufflations  to 
cases  in  which  it  is  desirable  to  apply  sedatives  and  to  keep  them  in  contact  with  an 
elevated  or  otherwise  painful. spot;  but,  as  I have  already  said,  I am  not  an  advocate  of 
insufflations  as  a general  method  of  conveying  topical  remedies,  for  I have  not  unseldom 
seen  them  coughed  away  as  a thick  cake  a second  or  two  after  their  introduction,  and 
if  I wish  to  have  a sedative  retained  I prefer  a semi-fluid  or  emulsive  medium  of  traga- 
cantli.  Cocaine  has,  of  late  years,  taken  preeminence  as  a pain  destroyer,  and  is  of 
undoubted  value  lor  allaying  sensibility  of  the  throat  to  the  passage  of  food  when  adyn- 
phagia  is  a prominent  symptom  ; but  morphia,  whether  in  powder  or  in  semi-fluid 
medium,  and  balsamic  applications  containing  some  preparation  of  opium  or  belladonna, 
are  of  more  service  in  diminishing  continuous  pain  and  in  allaying  cough,  since,  the 
action  of  these  drugs  is  far  less  transitory  than  in  that  of  cocaine.  Cocaine  lozenges  are 
useful  in  tuberculosis  of  the  tongue  and  fauces.  They  are  of  no  avail  in  laryngeal  cases. 

Before  the  introduction  of  cocaine,  I found  great  comfort  was  experienced  from  appli- 
cation of  a mixture  of  compound  tincture  of  benzoin  and  paragoric,  each  an  ounce,  and 
a drachm  of  tincture  of  belladonna  mixed  up  with  the  yelk  of  one  egg.  Patients  were 
allowed  to  apply  it  themselves  before  food  taking  and  on  occurrence  of  cough.  I still 
employ  this  mixture,  substituting  cocaine  in  place  of  the  belladonna,  for  allaying  actual 
pain. 

Surgical  Measures. — These  are,  for  the  most  part,  heroic,  and  are  not  pursued  by  me 
further  than  to  the  extent  of  scrapings  prior  to  the  application  of  lactic  acid  or  menthol. 
It  is  hardly  necessary  to  speak  in  detail  of  incision  into  the  thickened  laryngeal  tissues, 
as  advised  seven  years  ago  by  Schmidt  and  also  advocated  by  Hering.  It  is  true  that 
general  periostitis  has  been  treated  successfully  by  stabbings  and  incisions ; neverthe- 
less, my  experience  of  quite  slight  scarification  of  the  larynx  of  a tuberculous  patient, 
even  where  the  swelling  of  the  tissues  seemed  to  be  due  to  true  oedema,  has  not 
encouraged  me  to  further  extend  the  practice.  Such  points  rarely,  if  ever,  heal,  and 
are  only  too  likely  to  become  the  seats  of  fresh  infection.  I doubt  if  there  are  many 
practitioners  who  have  longer  any  faith  in  the  treatment.  Neither  do  I advise  removal 
of  the  granulomata  and  other  papillomatoid  excrescences  so  frequently  observed  in  the 
course  of  a tuberculous  laryngitis,  unless  they  are  in  such  situation  as  to  seriously 
interfere  with  respiration.  Nor  have  I yet  seen  my  way  to  the  advocacy  of  tracheotomy, 
either  as  a prophylactic  or  as  ameliorative  of  the  distressing  respiratory  symptoms  so 
often  evidenced  in  laryngeal  phthisis.  My  main  objection  is  that  the  theoretical  indi- 
cation on  which  the  operation  is  based — namely,  the  giving  functional  rest  to  the  larynx 
— is  but  very  rarely  attained  in  practice.  On  the  contrary,  a tracheotomy  tube  is  almost 
always  a source  of  extreme  irritation  and  increased  discomfort  in  the  case  of  a tubercu- 
lous patient.  Added  to  this,  the  physiological  duties  of  the  upper  air  passages  are 
entirely  abrogated,  and  the  air  is  taken  into  the  lungs  impure,  cold  and  dry.  In  this 
manner  the  operation  is  actually  capable  of  inducing  an  aggravation  or  recrudescence 
of  pulmonary  disease,  unless  the  patient  is  confined  to  a room  and  made  to  inhale  an 
atmosphere  charged  with  steam  and  antiseptics. 

Nor  can  I speak  favorably  of  the  prospects  to  be  afforded  by  the  recently  revived 
procedure  of  intubation  of  the  larynx,  which  has  the  additional  objection  of  causing 
increased  irritation  by  constant  contact  of  a foreign  body  with  tissues  already  ulcerated 
or  highly  prone  to  become  so.  The  risk  of  blocking  of  the  very  small  tubes  used  in 
these  operations,  by  tenacious  secretions  and  sputa,  constitutes  an  adverse  argument 


SECTION  XIII — LARYNGOLOGY. 


25 


that  must  not  be  overlooked.  For  fear  of  bringing  valuable  surgical  measures  into 
disrepute,  I go  so  far  as  to  never  remove  even  an  elongated  uvula  in  a tuberculous 
subject  without  most  explicitly  warning  both  the  patient  and  his  friends  that  the 
operation  is  but,  at  best,  a palliative.  Far  less  could  I approve  the  suggestion  to  remove 
a portion  of  thickened  epiglottis  or  arytenoid  body.  But  to  show  the  length  to  which 
surgical  measures  may  be  extended,  I need  only  mention  that  Massei  has  recently 
suggested  that  “the  history  of  many  successful  cases  of  extirpation  of  glands,  kidneys, 
ovaries  and  other  organs  for  tubercular  disease  warrants  us  in  entertaining  the  idea  that, 
were  early  diagnosis  of  primary  laryngeal  phthisis  possible,  extirpation  of  the  larynx 
in  such  instances  would  come  within  the  pale  as  the  most  efficacious  of  all  remedies.  ’ ’ 
It  is  hardly  necessary  for  me  to  say  that  I do  not  share  such  an  opinion. 

After  all  is  said  and  done,  are  we  in  a position  to-day  to  claim  that  we  can  cure 
laryngeal  phthisis?  I personally  doubt  it,  and  although  I have  alluded  to  two  cases 
occurring  in  my  own  practice,  in  which  there  has  been  apparently  complete  arrest  of 
all  diseased  processes,  I am  unable  to  report  one  in  which  I have  seen  what  could  fairly 
be  called  a cure,  by  either  physic  or  surgery,  of  a case  of  well-established  laryngeal 
phthisis.  I could  present  you  with  a table  of  many  carefully- watched  observations,  by 
which  it  could  be  shown  that,  under  treatment  such  as  has  been  indicated  as  that 
generally  adopted  in  my  practice,  the  following  gratifying  results  have  taken  place  : — 

1.  Food  taking  has  been  rendered  painless  or  less  painful,  and  regurgitation  of  fluids 
has  been  especially  obviated.  As  a consequence,  weight  has  been  gained. 

2.  Expectoration  and  secretion  have  both  been  lessened. 

3.  Erosions  have  healed,  but  rarely  ulcerations,  except  in  the  fauces  and  pharynx. 
In  this  respect  I am  able  to  concur  heartily  with  the  dictum  of  Hunter  Mackenzie,  that 
success  in  treatment  is  in  proportion  to  the  accessibility  of  the  seat  of  the  lesion.  When 
the  vocal  cords  are  implicated,  I have  but  rarely  witnessed  material  improvement  in  the 
vocal  symptoms. 

4.  The  pulmonary  condition  has  remained  in  some  cases  stationary,  in  others  the 
morbid  process  has  been  retarded,  and  in  a third  class,  although  lung  disease  has  been 
far  advanced,  and  has  continued  active,  improvement  of  throat  symptoms,  especially  of 
pain  and  difficulty  in  food  taking,  has  been  really  considerable. 

5.  Hectic  sweats  have  in  many  cases  been  diminished,  even  where  the  chart  has  not 
shown  great  variations  of  temperature. 

On  the  whole,  I have  to  confess  that  evidence  of  local  relief  has  been  more  satisfac- 
tory than  that  pointing  to  any  real  arrest  of  the  disease,  and  we  must  still  admit  that 
faucial  or  laryngeal  tuberculosis,  being  rarely  primary,  is  but  partially  amenable  to 
therapeutics,  and  that  its  existence  in  the  throat  as  a complication  of  a pulmonary 
tuberculosis  must  always  influence  our  prognosis  most  unfavorably,  whether  we  calcu- 
late on  the  chances  of  an  arrest  of  the  disease  or  on  the  probable  duration  of  a life. 

But  while  I am  precluded  from  reporting  such  a happy  experience  as  those  of 
Schmidt,  tiering,  Bosworth  and  others,  who  claim  to  have  quite  a long  list  of  cures,  I 
am  far  from  denying  such  a possibility.  On  the  contrary,  I feel  sure  that  each  year 
we  are  encouraged  in  the  belief  that  there  is  at  least  equal  hope  that  such  a result  may 
in  time  be  attained,  when  the  disease  attacks  the  throat,  as  is  at  present  held  out 
regarding  its  manifestations  in  the  chest. 

For  this  desirable  end  what  is  required  is:  First,  earlier  diagnosis  and  treatment  of 
premonitory  morbid  conditions. 

Secondly,  greater  reticence  in  advertising  the  infallibility  of  new  remedies,  and 
adoption  only  of  such  as  are  based  on  sound  pathological  data. 

Thirdly,  abstinence  from  “useless  activity,”  as  Paget  has  called  it,  especially  in 
advanced  cases,  and  a recognition  of  the  fact  that  an  attempt  should  be  made  to  heal 
the  nidus  as  well  as  to  destroy  the  bacillus  which  is  settled  thereon. 


2G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Lastly,  and  above  all,  to  again  quote  the  words  of  Sir  James  Paget,  “The  chief  need 
seems  to  be  the  collection  of  facts  well  observed  by  many  persons.  I say  by  many,  not 
only  because  many  facts  are  wanted,  but  because,  in  all  difficult  research  it  is  well 
that  apparent  facts  should  be  observed  by  many;  for  things  are  not  what  they  may 
appear  to  each  one’s  mind.  In  that  which  each  man  believes  that  he  observes  there  is 
something  of  himself,  and  for  certainty  even  on  matters  of  fact  we  often  need  the 
agreement  of  many  minds,  that  the  personal  element  of  each  may  be  counteracted.” 

DISCUSSION. 

Dr.  J.  Sinclair  Cogiiill,  of  London,  opened  the  discussion  on  this  paper  by  say- 
ing— I have  listened  to  Mr.  Browne’s  communication  with  the  same  pleasure  and 
instruction  I always  receive  from  that  gentleman’s  contributions  to  the  literature  of 
that  branch  of  medicine  which  he  has  cultivated  so  successfully.  There  is  no  form 
or  complication  of  phthisis  which  causes  so  much  distress  to  the  patient  and  embar- 
rassment to  the  physician  as  tubercular  laryngitis.  It  is  of  first  importance  to  dis- 
tinguish between  tubercular  laryngitis  as  a primary  and  as  a secondary  lesion. 
This  is  more  especially  important  as  a basis  of  opinion  in  prognosis.  As  a secondary 
affection,  the  physician  must  content  himself  with  relieving  symptoms  with  a view  to 
alleviate  the  evident  and  distressing  sufferings  of  the  patient.  As  a primary  affec- 
tion we  can  hope  to  decrease,  in  the  light  of  modern  discoveries,  the  prognosis  is 
vastly  less  grave,  and  at  least  we  can  regard  a pause  in  the  progress.  It  was  long 
before  I could  convince  myself  that  laryngeal  phthisis  was  ever  other  than  a lesion 
secondary  to  pulmonary  tuberculosis.  I have  no  doubt  whatever,  now,  that  it  does 
occur  as  a primary  disease  from  infection.  It  would  indeed  be  strange  if  this  were 
not  to  occur  occasionally  if  the  lungs  are  infected  through  the  air  passages,  as  they 
most  undoubtedly  are.  One  case  recently  under  my  care  threw  a most  instructive 
light  in  this  connection.  A young  lady  contracted  a tubercular  ulceration  of  the 
left  side  of  the  pharynx,  extending  down  to  and  involving  the  margin  of  the  epi-  1 
glottis.  Repeated  examination  of  the  chest  revealed  no  pulmonary  mischief.  The 
disease  was  contracted  while  nursing  a brother  who  died  of  chronic  pulmonary 
phthisis  involving  both  lungs.  The  patient  in  question  had  all  the  usual  symptoms 
of  tuberculosis.  Iodoform  applied  locally,  with  extreme  care,  in  association  with 
apropriate  general  treatment,  entirely  cured  the  case.  I know  no  remedy  equal  to 
iodoform,  but  it  is  a potent  one,  and  must  be  used  sparingly  and  cautiously.  I have 
seen  toxic  effects  repeatedly  developed  from  comparatively  small  doses.  I cannot  tell 
what  its  mode  of  action  may  he ; it  is  possible,  as  Mr.  Cheyne  says,  that  ‘ ‘ the  tubercle 
bacillus  perishes  in  the  purity  of  iodoform;”  but  there  is  no  topical  remedy  I have 
employed  with  so  much  confidence  and  satisfaction  in  tuberculosis,  nay,  indeed,  in  any 
foul  ulceration,  as  iodoform.  I must  confess  I am  not  sound  on  the  tubercle  bacillus.  • 
My  heterodoxy,  however,  only  goes  the  length  of  referring  the  processes  in  which  it 
may  be  recognized  as  more  due  to  its  nidus  or  environment,  than  to  the  bacillus  itself. 
This  is  most  important  to  bear  in  mind,  as  the  importance  of  general  treatment  in 
such  cases  take  this  foreground  in  one  regard.  Tuberculosis  is  essentially  a parasit- 
ical disease,  and  this  fact  must  be  continually  borne  in  mind.  I might  illustrate  this 
from  what  is  so  familiar  to  us  in  the  vegetable  world.  When  a tree  has  deficient  air 
and  light,  its  roots  cramped  in  by  barren  soil,  it  gets  sickly,  looks  ill,  gets  out  of  con- 
dition and  speedily  becomes  the  prey  of  every  parasitic  pest.  Remove  the  unhealthy 
condition,  let  in  air,  light  and  sunshine,  loosen  the  roots  and  furnish  rich  soil,  and 
the  change  for  the  better  begins,  health  is  restored,  and  the  parasites  cease  to  flour- 
ish. This  is  seen  in  phthisis  in  states  of  arrest ; bacilli  may  be  found,  but  the  condi- 


SECTION  XIII — LARYNGOLOGY. 


27 


tions  for  their  development  are  absent.  This  question  of  raising  and  restoring  the 
general  health  is  not  only  true  with  respect  to  the  recovery  from  disease,  but  also  in 
resisting  morbid  influences.  Note  the  different  fate  of  twelve  robust,  well-fed  and 
vigorous  men,  and  a similar  number  of  feeble  and  starved  men,  exposed  to  the  infection 
of  sewer  gas.  I must  refer,  before  sitting  down,  to  Bergeon’s  treatment.  I believe  it 
has  no  specific  action  in  tuberculosis  of  lungs  or  larynx.  It  is  only  improving  in  the 
general  health  through  the  gastro-intestiual  mucous  membrane,  improving  action  of 
liver,  digestion  and  assimilation,  just  as  sulphureted  waters  have  been  doing  for 
ages,  when  taken  by  the  stomach.  The  case  Mr.  Lennox  Browne  has  referred  to  was 
one  that  improved  marvelously  under  treatment.  Indeed,  it  encouraged  me  vastly  to 
believe  in  its  efficacy.  No  case  could  have  presented  a greater  consensus  of  unfavor- 
able conditions,  both  as  regards  the  morbid  history  and  the  inherited  cachexia,  but  that 
the  patient  seemed  to  revive  miraculously,  profoundly  impressed  me  with  the  benefit 
he  had  derived.  I think  he  confirms  the  treatment  too  energetically  with  the  results 
stated. 

Dr.  J.  Solis-Cohen,  of  Philadelphia  had  frequent  occasion  to  corroborate 
mostly  the  views  of  the  reader  of  the  paper,  especially  those  of  the  last  speaker, 
with  whom  he  had  seen  much  advantage  from  the  topical  use  of  iodoform,  and  with 
whom  he  thought  the  great  elements  in  treatment  are  to  improve  the  general  con- 
dition of  the  tissues  so  as  to  disfavor  the  development  of  bacilli,  and  render  them 
more  innocuous,  and  to  depend  upon  nutrition  as  the  main  resource  in  treatment. 

Prof.  E.  Fletcher  Ingals,  of  Chicago,  said — Like  the  preceding  speakers, 
I fully  agree  with  nearly  all  that  has  been  said  by  the  author  of  the  paper,  and  I 
desire  to  call  special  notice  to  some  of  the  points  which  have  been  made,  with  a view 
of  emphasizing  them.  I was  especially  pleased  to  learn  that  the  author  had  given 
up  the  use  of  steam  inhalations,  and  I wish  every  one  else  would  give  them  up,  for 
I believe  that  in  most  cases  they  do  more  harm  than  good.  Regarding  climatic 
treatment,  I am  uncertain  what  cases  of  laryngeal  tuberculosis  are  benefited  by  a 
high  altitude.  I now  think  that  those  in  which  the  disease  is  recent  may  be  bene- 
fited, but  I am  confident  that  many  cases  of  advanced  ulceration  are  greatly  injured 
by  it.  I fully  agree  with  the  author  that  the  salts  of  calcium  seem  most  beneficial. 
I do  not  know  that  it  matters  materially  what  salt  be  used,  but  from  several  years’ 
use  I have  come  to  like  best  the  chloride,  which  is  readily  soluble  and  easily 
absorbed.  Bergeou’s  treatment  I have  tried,  and  in  one  case  of  laryngeal  phthisis 
found  it  beneficial  for  a few  days,  but  afterward  it  caused  such  severe  pain  that  the 
treatment  had  to  be  suspended.  I have  had  little  experience  with  the  superficial 
application  of  lactic  acid,  and,  fortunately,  but  little  with  the  submucous  injection. 
In  only  two  cases  have  I tried  the  latter ; in  both  the  effects  were  not  good,  and 
the  patients  went  rapidly  “to  their  reward.”  I have  had  very  little  satisfaction 
from  the  use  of  cocaine  for  the  relief  of  pain,  either  when  applied  by  myself  or  when 
used  as  an  insufflation  by  the  patient  shortly  before  eating.  I have  had  better 
results  in  these  cases  in  relieving  pain  from  the  application  of  a pigment  of  morphine, 
carbolic  acid  and  tannin  in  glycerine  and  water.  I believe  that  the  combination  of  the 
tannin  with  the  glycerine  hardens  the  tissues,  and  thus  materially  aids  in  preventing 
pain.  As  to  the  prognosis,  I can  now  recall  four  cases,  in  two  of  which  there 
were  ulceration,  and  in  the  others  erosions,  in  whom  recovery  had  taken  place.  In 
these  the  diagnosis  was  not  made  by  the  aid  of  the  microscope,  but  in  all  of  them 
were  pronounced  pulmonary  lesions.  These  cases  are  of  from  four  to  seven  years’ 
duration.  The  two  of  whose  present  condition  I am  certain  have  pulmonary  scars. 
With  the  second  speaker  I fear  I am  not  orthodox  on  the  subject  of  bacilli,  but 


28 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


believe  that  the  bacillus  is  not  of  so  much  importance  as  the  soil  upon  which  it 
thrives.  This  recalls  the  case  of  a brother  physician  suffering  from  laryngeal  tuber- 
culosis iu  which  the  number  of  bacilli  are  greatly  increased  by  the  occurrence  of  cold. 

It  seems  as  though  in  this  case  it  must  surely  be  the  soil  that  causes  the  increase. 
Finally,  as  I said  many  years  ago,  I believe  that  constitutional  treatment  is  of  great- 
est importance,  though  I also  believe  that  local  treatment  is  of  much  value.  If  the  < 
condition  of  treatment  can  be  improved,  we  may  hope  to  benefit  the  larynx,  but  local  i 
treatment  can  hardly  help  other  cases,  excepting  as  they  prevent  pain  and  thus  allow 
of  proper  nutrition. 

Dr.  Coomes,  of  Louisville,  Ky. , said  that  a few  years  since  he  was  in  doubt  as  to 
the  possibility  of  phthisis  of  the  larynx  occurring  without  involvement  of  the  lungs,  J 
but  at  present  he  was  satisfied  that  the  larynx  might  be  involved  without  the  exist- 
ence of  tubercle  iu  other  portions  of  the  body.  He  reported  four  cases  in  which  the  j 
disease  of  the  larynx  was  arrested  during  the  existence  of  the  lung  complication.  In 
two  cases  the  epiglottis  was  almost  completely  destroyed,  but  the  open  surface  in 
each  completely  healed ; one  of  the  patients  is  still  living,  the  other  died  eighteen 
months  after  the  throat  lesion  was  cured,  from  pulmonary  hemorrhage.  He  pre- 
ferred iodoform  insufflations  to  all  other  local  applications ; was  careful  to  apply  it  in 
small  quantities,  two  grains  being  quite  sufficient.  Had  seen  two  cases  of  severe 
poisoning  from  its  use  in  large  doses. 

Dr.  Max  Thorner,  of  Cincinnati,  Ohio,  said — I think  that  tuberculous  ulcer- 
ation in  early  stages  may  heal,  even  if  only  temporarily.  The  presence  of  bacterii 
tuberculosis  seems  not  to  be  necessary,  since  other  symptoms  often  will  prove  the  ' 
presence  of  tuberculosis.  Dr.  Bryson  Delavan,  of  N.  Y. , reported  in  the  last  meet- 
ing of  the  American  Laryngological  Association  cases  of  tuberculous  ulcers  of  the 
tonsils,  where  he  did  not  find  bacilli.  I have  seen  two  cases  of  laryngeal  phthisis  in 
which  tuberculous  ulceration  was  present,  though  I admit  of  not  having  found  bacilli 
tuberculosis.  One  gentleman  had  ulcers  on  the  vocal  cords;  he  complained  of  pain  | 
radiating  from  the  left  side  of  larynx  to  the  ear.  The  apices  of  the  lungs  showed  | 
acute  bronchitis.  After  using  iodoform  and  boric  acid  for  about  two  months,  the 
ulcers  healed.  Six  months  afterward  the  patient  came  with  the  same  symptoms  ; 
the  same  treatment  had  the  same  effect. 

In  the  second  case,  a young,  emaciated  man  was  exceedingly  hoarse,  complained 
of  severe  pain  radiating  from  both  sides  of  the  larynx  to  the  ears.  The  vocal  cords 
were  superficially  ulcerated.  The  left  arytenoid  cartilage  had  the  pathognomonic 
pyriform  shape.  There  was  no  active  process  in  the  lungs ; both  apices  had  a dull 
percussion  sound.  The  ulcers  healed  twice,  in  intervals  of  about  six  months  after, 
with  the  application  of  iodoform  and  lactic  acid.  When  he  appeared  the  third  time 
with  the  same  symptoms,  I treated  him  alone,  according  to  Bergeon’s  plan  ; after  six 
weeks  there  was  no  improvement  at  all  in  the  laryngeal  symptoms.  I then  again 
treated  him  with  forty  per  cent,  solution  of  lactic  acid ; the  ulcers  healed  in  about 
eight  weeks.  These  two  cases  seem  to  prove  to  me  that  laryngeal  tuberculous  ulcers  i 
may  heal  temporarily. 

Dr.  McGeagh,  of  London,  reported  one  case  under  observation  at  University 
Hospital,  London,  remarkable  for  the  marked  improvement  during  the  exhibition  of 
iodide  of  potassium,  ten  grains  three  times  a day,  with  the  local  application  of  equal 
parts  of  iodoform,  boric  acid  and  starch  by  insufflation,  after  having  the  throat  first  ; 
of  all  thoroughly  cleansed  by  a camel’ s-hair  brush  saturated  with  an  antiseptic  solu-  1 
tion.  This  case  gained  at  the  rate  of  five  pounds  a week  for  a period  of  several 


SECTION  XIII — LARYNGOLOGY. 


29 


weeks;  finally  he  left  with  his  throat  partially  healed  and  his  general  condition  mani- 
festly improved. 

Prof.  Casselberry,  of  Chicago,  remarked — There  are  formidable  cases  which 
tax.  our  utmost  resources.  Lactic  acid  has  been  highly  lauded,  and  as  strongly  con- 
demned. Rational  selection  of  cases  is  necessary  to  obtain  good  results.  The  treat- 
ment is  accompanied  by  considerable  after  pain  and  cough,  which  is  badly  borne  by 
debilitated  subjects.  Comparatively  sthenic  subjects,  with  circumscribed  laryngeal 
lesions,  so  treated,  are  the  ones  which  recover. 

Thorough  cleansing  of  the  parts  is  an  essential  preliminary  to  all  local  applica- 
tions. An  alkaline  spray,  to  which  a small  percentage  of  thymol  may  be  added,  is 
useful  for  this  purpose;  iodol  by  insufflation  is  a useful  substitute  for  iodoform.  It 
is  lighter,  and  consequently  more  diffusible.  Ethereal  solutions  of  iodoform  are  irri- 
tant, because  of  the  irritant  qualities  of  ether.  Liquid  vaseline  probably  is  a better 
vehicle.  Morphine  is  a better  local  sedative  for  continuous  use  than  cocaine,  the 
reaction  from  the  latter  maintaining  congestion  of  the  parts.  I have  observed  spon- 
taneous recovery  of  the  vocal  laryngeal  lesions  during  the  progress  of  the  pulmonary 
tuberculosis. 

Prof.  Stockton,  of  Chicago,  said — I am  quite  in  accord  with  Mr.  Browne, 
that  mountain  and  ocean  air  are  only  applicable  to  recent  cases.  Lactic  acid  I have 
used,  but  found  that  the  cases  must  be  selected.  Iodoform  I consider  the  medica- 
tion par  excellence;  the  ulcer  must  be  carefully  cleansed,  and  then  only  a small 
quantity  of  iodoform  is  necessary,  as  it  should  be  localized  to  the  ulcer.  Cocaine  is 
only  useful  for  examinations,  and  must  not  be  used  for  any  length  of  time.  I cannot 
see  how  iodide  of  potash  can  be  of  use  in  this  disease,  unless  it  is  one  of  those  com- 
plicated cases  such  as  I have  had  the  pleasure  of  seeing  in  Vienna,  from  one  of  the 
rare  cases  on  the  post-mortem  table. 

Dr.  John  N.  Mackenzie,  of  Baltimore,  Md.,  shared  the  skepticism  shown 
by  some  of  his  colleagues  in  regard  to  the  bacillus  theory  of  tuberculosis.  If  the 
bacilli  be  inhaled,  why  is  it  that  tuberculosis  of  the  nasal  passages  is  not  more  fre- 
quently met  with.  While  he  believed  that  laryngeal  ulcers  tubercular  in  nature 
occasionally  heal,  the  probability  is  not  to  be  overlooked  that  the  so-called  tubercu- 
lar ulcer  can  be  none  other  than  the  diphtheritic  ulcers  of  the  windpipe,  so  common 
in  general  tuberculosis.  Dr.  M.  insisted  on  general  treatment,  commended  the  local 
use  of  iodoform  and  a weak  spray  of  bichloride  of  mercury.  The  question  of  pri- 
mary laryngeal  tuberculosis  can  only  be  settled  by  the  scalpel;  that  had  already  been 
done  by  Orth. 

Dr.  Lester  Curtis,  of  Chicago,  remarked  that  he  had  been  listening  to  the  dis- 
cussion in  the  hope  of  hearing  mention  of  a line  of  treatment  that  he  had  followed 
in  the  case  of  a lady  with  a large  cavity  of  one  lung  and  extensive  consolidation  of 
the  other.  She  had  a temperature  of  103°  Fahrenheit  or  over,  and  the  other  usual 
symptoms  of  advanced  phthisis.  On  the  use  of  quinine  in  pretty  full  doses,  the 
temperature  fell  to  somewhat  near  normal,  and  all  her  symptoms  improved  to  such  an 
extent  that  she  considered  herself  nearly  well,  and  continued  so  for  nearly  a year. 
In  regard  to  tuberculosis  of  the  larynx,  some  eight  or  ten  years  ago,  a case  came 
to  him  with  ulceration  of  the  arytenoid  cartilages,  with  great  difficulty  of  swallow- 
ing. He  was  put  upon  a treatment  of  a spray  of  nitrate  of  silver.  In  a very  short 
time  the  difficulty  diminished  greatly;  he  continued  much  better  for  a month  or 
two,  when  he  passed  out  of  observation.  In  this  case  there  was  a considerable 


30 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


consolidation  of  both  apices.  Another  case  of  advanced  phthisis,  cavities  in  both 
apices,  ulceration  at  the  base  of  both  arytenoids  and  great  difficulty  of  swallowing;  j 
on  treatment  by  nitrate  of  silver  the  dysphagia  nearly  disappeared,  continued  absent  : 
for  three  or  four  weeks,  when  he  died  by  the  natural  progress  of  the  lung  lesion. 

Dr.  Coghill,  of  London,  closed  the  discussion  by  remarking — In  view  of  the 
limited  time  at  my  disposal,  and  the  very  thorough  manner  this  subject  has  been 
threshed  out  by  the  various  speakers,  I shall  close  the  debate  in  a very  few  words,  | 
The  number  of  speakers  and  the  very  interesting  views  and  experiences  brought  for-  j 
ward  testify  to  the  importance  and  value  of  Mr.  Lennox  Browne’s  paper.  It  is  ! 
satisfactory  to  note  how  agreed  all  are  with  the  correctness  of  the  views  enunciated  j 
and  the  principles  for  treatment,  general  and  local,  so  precisely  and  fully  laid  down 
by  Mr.  Lennox  Browne.  I must  conclude  by  expressing  the  great  pleasure  with 
which  I have  taken  part  in  this  extremely  interesting  and  valuable  discussion. 

Mr.  Lennox  Browne,  of  London,  commenced  his  reply  by  thanking  the  i 
Section  for  the  generous  reception  of  his  communication,  and  by  congratulating  him- 
self on  the  discussion  that  had  been  raised.  He  expressed  himself  in  entire  agree- 
ment with  those  who  had  dwelt  on  the  primary  importance  of  climate,  hygiene  and  • 
general  treatment,  both  medical  and  dietetic.  In  fact,  he  had  discussed  these ; 
subjects  first  in  his  paper.  But  he  also  urged  that  though,  in  many  cases,  a 
pharyngeal  or  laryngeal  tuberculosis  was  but  a complication  of  a similar  lesion  in  the  j 
lungs,  the  pain  and  distress  which  it  occasioned  called  for  all  our  energies,  and  he ; 
expressed  his  belief  that  in  no  disease  of  the  throat  had  the  specialist  done  more ; 
serviceable  work  or  more  thoroughly  justified  his  position  than  in  the  great  advances ; 
that  have  been  made  in  the  palliation,  and  possibly  even  cure,  of  the  evidences  of 
this  malady  in  the  throat.  This  had  been  done,  not  by  general  therapeutic  meas-| 
ures,  to  improvement  of  which  laryngologists  have  contributed  little,  but  by  remedies  j 
applied  locally.  It  was  therefore  fit  that  local  means  of  treatment  should  occupy 
the  most  prominent  place  in  a discussion  on  this  subject,  in  a Section  devoted  to 
laryngology.  With  regard  to  climate,  he  concurred  with  the  speakers  who  con- 
sidered high  altitudes  most  suited  to  early  stages  and  deleterious  in  the  later ; the 
criteria  for  judgment  on  this  head  were  in  no  sense  different  from  those  regulating  • 
advice  in  general  pulmonary  disease.  He  was  forced  to  the  conclusion  that  the 
result  of  the  case  treated  successfully  by  iodide  of  potassium  was  one  of  syphilis,  for,  ! 
from  his  experience  with  the  drug  which  had  been  so  ardently  advocated  by  Moretz 
Schmidt,  of  Milan,  in  1880,  its  effects  in  a tme  tuberculosis  were  actually  harmful. 

In  response  to  the  doubts  expressed  by  many  speakers  as  to  the  part  played  by 
bacilli  as  primary  factors  of  tubercle,  the  author  expressed  himself  as  by  no  meaus 
indissolubly  wedded  to  the  view.  He  had  given  it  as  the  most  recent,  and  as  one 
almost  universally  accepted  in  the  present  day.  It  certainly  offered  one  of  the  best; 
data  for  treatment  that  has  yet  been  afforded.  He  thought  it  quite  possible  that 
many  remedies,  such  as  iodoform,  so  generally  extolled  by  all  who  had  spoken,  might 
act,  as  suggested  by  Dr.  Coghill,  in  such  a way  on  the  soil  in  which  the  bacteria  were 
manifested  as  to  hinder  their  growth  and  multiplication,  even  though  the  drug 
might  not  be  germicidal;  and  doubtless  the  tendency  of  the  day  was  to  pay  too  much 
attention  to  the  bacilli,  to  the  neglect  of  the  nidus.  Against  such  neglect  he  had 
spoken  in  his  paper.  With  regard  to  local  treatment,  as  Prof.  Casselberry  had 
wisely  drawn  attention  to  the  importance  of  selecting  cases  for  particular  remedies,  his 
remarks  were  important  as  emphasizing  a point  only  lightly  attended  to  in  the  paper. 


SECTION  XIII — LARYNGOLOGY. 


31 


Lastly,  as  to  cure  of  the  ulcer,  it  was  largely  a question  of  opinion  as  to  what  was 
recognized  as  a truly  tubercular  ulcer.  Without  doubt  such  lesions  were  healed  in 
the  fauces  and  supra-glottic  region.  He  personally  doubted  if  the  same  happy  result 
occurred,  save  as  au  exception,  in  the  larynx,  and  he  was  pleased  to  find  that  Drs. 
Cohen  and  John  N.  Mackenzie  agreed  with  him,  that  those  that  did  best  were,  in  the 
majority  of  instances,  not  truly  tuberculosis. 


Dr.  A.  G.  Hobbs,  of  Atlanta,  Ga.,  read  a paper  on — 

THE  NERVOUS  PHENOMENA  OBSERVED  IN  A CASE  OF  EXPO- 
SURE OF  THE  ANTERIOR  COLUMN  OF  THE  CORD 
FROM  SYPHILITIC  ULCERATION  OF  THE 
UPPER  PHARYNX. 

LES  PHENOMENES  NERVEUX  OBSERVES  DANS  UN  CAS  D’EXPOSITION  DE  LA 
COLONNE  ANTERIEURE  DE  LA  CORDE  PAR  SUITE  D’ULCERATION 
SYPHILITIQUE  DU  PHARYNX  SUPERIEUR. 

DIE  NERVOSEN  PHaNOMENE  BEI  EINEM  FALL  VON  BLOSLEGUNG  DER  RUCKENMARKS- 
VORDERSTRANGE  DURCH  SYPHILITISCHE  EITERUNG  DES 
OBEREN  PHARYNX. 

BY  A.  G.  HOBBS,  M.  D., 

Of  Atlanta,  Ga. 

In  October  last  a young  man  was  brought  to  my  office  to  be  treated  for  “ulcerated 
sore  throat,”  as  his  father  expressed  it.  He  had  been  a cowboy  in  Texas  for  two  years, 
strong  and  robust,  weighing  140  pounds.  When  he  reached  me  he  was  thin,  pale  and 
anaemic,  weighing  only  104  pounds. 

He  denied  ever  having  had  syphilis,  nor  had  he  any  evidence  of  this  disease  other 
than  the  ulcer  about  to  be  described,  and,  according  to  his  own  history,  there  never  had 
been  any  other  symptom  of  syphilis. 

A posterior  rhinoscopic  examination  revealed  an  ugly  sloughing  ulcer  in  the  poste- 
rior and  superior  wall  of  the  pharynx,  about  the  size  of  a silver  quarter.  Ey  the  use 
of  a soft  palate  retractor  a direct  view  of  a greater  part  of  the  ulcer  could  be  obtained. 
A bent  probe  discovered  necrosed  and  detached  bone  at  the  depth  of  about  half  an  inch, 
a piece  of  which  I succeeded  in  extracting  at  the  first  sitting.  At  each  succeeding  daily 
visit,  for  two  weeks,  small  pieces  of  bone,  from  the  size  of  a pin  head  to  a small  pea, 
were  either  washed  out  with  the  cleansing  syringe  or  extracted  with  the  probe  or 
scoop.  My  index  finger  would  now  enter  the  cavity  as  far  as  the  first  joint,  by  which 
means  I could  discover  either  detached  or  jagged  undetached  bones. 

The  treatment  had  from  the  beginning  been  based  upon  the  assumption  that  it  was 
a syphilitic  ulcer,  notwithstanding  his  repeated  denials  of  ever  having  contracted  the 
disease,  and  his  father’s  assurance  that  he  had  been  healthy  from  infancy  and  could 
not,  therefore,  have  inherited  the  taint. 

He  began  on  forty  grains  of  iodide  of  potash,  three  times  a day,  in  a menstruum 
of  succus  alterans ; this  dose  was  afterward  doubled.  The  ulcer  was  daily  cleansed 
with  cotton  probes,  syringes  and  sprays.  Sprays  were  applied,  not  only  directly,  but 
through  the  nose,  on  account  of  the  discharge  being  partly  expelled  through  that 
channel. 


32 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Listerine  was  used,  for  its  disinfectant  and  cleansing  properties,  and  nitrate  of  silver, 
full  strength,  was  applied  to  the  bottom  of  the  cavity  by  a cotton  probe,  after  which  the 
cavity  was  packed  with  iodol. 

About  this  time,  after  four  or  five  weeks  of  daily  treatment,  the  nervous  phenomena 
first  occurred. 

For  a week  or  ten  days  he  had  been  complaining  of  constant  pain  in  the  hack  of  his 
head  and  neck,  which  caused  him  to  carry  his  head  to  one  side,  and  rigidly.  During 
this  latter  period — the  fourth  and  fifth  weeks — he  had  been  unable  to  sleep,  except  for 
a few  minutes  at  a time,  and  in  a sitting  posture. 

After  the  cavity  had  been  thoroughly  cleansed,  at  one  of  the  treatments,  I pressed 
the  nitrate  of  silver  probe  to  its  bottom,  when,  as  suddenly  as  if  he  had  been  shot,  one- 
half  of  the  patient’s  body  became  paralyzed  ; his  head  fell  to  the  right,  his  right  arm 
dropped  to  his  side,  his  right  leg  turned  outward,  and  he  would  have  fallen  from  the 
chair  if  I had  not  caught  him.  Without  losing  consciousness  at  any  time,  this  hemi- 
plegic condition  lasted  about  thirty  seconds,  when,  as  he  expressed  it,  ‘ ‘ he  felt  a tingling 
in  the  right  half  of  his  body,”  and  in  another  half  minute  he  slowly  raised  his  right 
side  into  position.  The  next  day  the  same  phenomenon  was  repeated,  but  on  the  opposite 
side.  The  pupil  on  the  side  affected  became  slightly  dilated,  but  the  perspiratory  glands 
did  not  seem  to  be  affected  during  the  paralysis. 

He  was  now  so  reduced  in  weight  (to  96  pounds)  and  in  strength,  by  the  loss  of 
sleep  and  constant  pain,  that  he  could  not  walk  to  my  office.  The  extreme  insomnia 
lasted  about  ten  days,  during  which  time  his  attendants  thought  he  did  not  sleep  one 
hour  in  twenty-four.  But  from  this  time  healing  began  at  the  bottom  of  the  ulcer,  the 
discharge  became  less,  and  examinations  with  the  finger  did  not  discover  any  more 
rough  bones  ; he  slept  better,  and  complained  less  of  the  pain  in  the  back  of  his  head 
and  neck. 

He  naturally  did  not  desire  that  a paralysis  should  be  deliberately  produced  now, 
because  he  was  not  certain,  nor  could  I with  much  confidence  assure  him,  that  it  would 
only  last  one  minute  if  repeated . A week  passed  on  with  all  of  his  symptoms  gradually 
improving,  when  I could  no  longer  resist  the  temptation  of  making  another  pressure 
with  the  probe. 

Paralysis  of  the  side  pressed  upon  was  again  exhibited,  but  in  a much  milder  degree 
than  before,' ending  in  the  same  tingling  sensations  as  described  before. 

As  only  the  spray  and  powder  blower  were  used  from  this  time  onward  in  dressing 
the  cavity,  no  more  pressures  with  the  probe  were  made  till  healing  had  well  progressed, 
probably  ten  days  or  two  weeks  after  the  last  test. 

To  my  surprise,  when  the  probe  was  now  pressed  into  the  cavity,  a condition  just 
the  opposite  of  paralysis  was  exhibited  ; the  arm  aud  leg  jerked  and  jumped  similar  to 
a case  of  chorea.  These  choreic  muscular  contractions,  uulike  the  paralysis,  lasted  only 
during  the  pressure  of  the  probe.  In  repeating  the  probe  pressures  at  intervals  during 
the  next  few  days,  the  same  choreic  symptoms  Avere  produced,  always  on  the  corre- 
sponding side  of  the  pressure,  but  in  a less  aud  less  degree,  requiring  a still  firmer 
pressure  to  produce  the  effect. 

Finally,  when  the  healing  process  had  been  thoroughly  established,  and  cicatricial 
tissue  had  in  a measure  closed  up  the  cavity,  only  a “ tingling  or  pricking  ” sensation 
followed  the  probe  pressure,  a sensation  similar  to  that  which  followed  the  hemiplegia 
in  the  first  instance.  After  the  cicatricial  tissue  had  thoroughly  hardened,  no  mani- 
festation folloAved  the  pressure  of  the  probe. 

At  the  time  of  writing,  ten  mouths  since  I first  suav  the  patient,  he  is  entirely 
recovered,  aud  presents  a perfect  picture  of  health.  His  weight  is  37  to  40  pounds 
more  than  he  weighed  in  November  of  last  year.  He  was  kept  on  a lessened  dose  of 
iodide  of  potash  and  succus  al tenuis  until  last  J uly. 


SECTION  XIII — LARYNGOLOGY. 


33 


I cannot  state  accurately  as  to  the  total  amount  of  dead  bone  taken  from  the  cavity, 
but  I should  say  that  its  area  would  about  equal  that  of  a medium-size  almond. 

The  sequel,  it  would  seem,  proved  my  diagnosis  to  he  correct,  since  the  ulcer  had 
gradually  increased  in  size  and  virulency  for  six  months  prior  to  the  beginning  of  the 
anti-syphilitic  treatment ; and  though  he  did  not  improve  at  once,  healing  did  begin  as 
soon  as  the  local  treatment  succeeded  in  cleansing  the  ulcer  of  necrosed  hone. 

The  case  is  of  even  greater  interest  to  the  neurologist  than  to  the  laryngologist,  and 
had  more  systematic  experiments  been  made,  and  closer  observations  been  taken  of  the 
nervous  phenomena,  something  of  greater  interest  might  have  been  gained. 

I will  confess  that  I had  not  the  temerity  to  risk  many  experiments  at  the  time  in 
the  progress  of  the  case  when  they  would  have  been  available. 

Some  important  points  may  be  noted  : — 

1.  The  necrosis  must  have  occurred  in  the  spinous  process  of  the  second  cervical 
vertebra  ; hence  the  spinal  cord  was  exposed  either  between  the  first  and  second  or  the 
second  and  third  vertebra. 

2.  The  probe  pressure  always  produced  its  effect  on  the  corresponding  side  of  the 
body. 

3.  The  pressure  that  produced  the  paralysis  must  have  wounded  the  anterior  column 
by  pressing  a jagged  piece  of  bone  against  the  cord,  and  the  pressure  that  produced  the 
convulsions  must  have  only  irritated  the  anterior  column,  since  it  is  well  known,  by 
experiments  on  the  lower  animals,  that  a wound  of  the  anterior  column  produces 
immediate  paralysis,  and  an  irritation  immediate  convulsions. 


RHEUMATIC  LARYNGITIS. 

LARYNGITE  RHUMATISMALE 
UBER  EHEUMATISCHE  LARYNGITIS. 

BY  E.  FLETCHER  INGALS,  A.M.,  M.D., 

Of  Chicago,  111. 

Rheumatic  laryngitis  is  a painful  affection  of  the  vocal  organ,  attended  by  more  or 
less  hoarseness  and  fatigue  of  the  parts  after  talking,  and  sometimes  by  grave  or  even 
fatal  obstruction  of  the  glottis.  The  affection  may  be  either  acute  or  chronic.  The 
acute  disease,  from  having  been  associated  with  articular  rheumatism,  has  been  recog- 
nized for  several  years,  but  it  has  been  hut  little  studied,  and  the  literature  of  the  sub- 
ject is  very  meagre.  Through  the  kindness  of  Dr.  J.  S.  Billings,  the  library  of  the 
Surgeon-general’s  office  has  been  searched  for  me,  but  we  have  succeeded  in  unearthing 
only  two  articles  upon  the  subject.  The  first  of  these,  from  a thesis  of  Dr.  E.  J.  R.  E. 
Emery-Desbrousses,*  1861,  relates  to  a case  of  acute  febrile  articular  rheumatism,  with 
laryngeal  localization,  which  terminated  fatally.  The  patient  was  a young  woman, 
twenty-four  years  of  age,  suffering  from  acute  articular  rheumatism  and  pericarditis.  On 
the  fourth  day  the  larynx  became  involved,  causing  aphonia  and  severe  pain,  with  suf- 
focative attacks,  which  continued,  with  varying  severity,  until  her  death,  from  slow 


* “ Rheumatisme  articulairo  aigu,  febrile  localisation  laryngfie  pericardite  et  pneumoni6 
mort.”  4to.  Strasburg,  1861— 25.  No.  544.— ( Thiae.) 

Vol.  IV— 3 


34 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


asphyxia,  on  the  twentieth  day.  At  the  autopsy  the  arytenoids  were  found  bare  hut  not 
necrosed,  and  on  the  left  side  a reddish,  serous  fluid  was  found  in  the  articulation, 
which  demonstrated  the  rheumatic  laryngeal  arthritis.  This  seems  to  have  been  the 
first  case  placed  on  record,  though  brief  references  to  the  affection  have  been  made  by 
Besmer,  Chomel,  Lieberman,  Dechamb  and  Prof.  Jaccoud,  and  cases  have  also  been 
recorded  by  Fauvel,  Coupard  and  Joal. 

The  second  paper  is  a very  complete  article  on  the  subject  by  R.  Archambault. 
( Th csis,  Paris,  1880.)  He  gives  a careful  history  of  the  literature  of  the  subject,  and 
has  collected  five  cases,  one  by  Emery  Desbrousses,  just  referred  to,  one  by  Fauvel  and 
two  by  Coupard  ; to  these  he  adds  the  history  of  one  which  came  under  his  own  obser- 
vation. From  these  cases  he  draws  the  following  conclusions  — 

“1.  Acute  laryngeal  manifestations  of  rheumatism  are  more  common  than  is  gener- 
ally supposed. 

“2.  These  manifestations  may  affect  separately  the  various  parts  of  the  larynx, 
mucous  membrane,  articulations,  muscles,  nerves. 

“3.  The  congestions  of  mucous  membranes  are  the  most  frequent  as  well  as  the  most 
easily  determined  of  the  lesions. 

“ 4.  They  may  give  rise  to  accidents  of  suffocation  grave  enough  to  necessitate  sur- 
gical intervention. 

“5.  The  other  manifestations  are  too  uncommon  and  too  little  known  to  make  a 
thorough  and  separate  study  of  them.” 

Treatment. — “Care  should  betaken  to  prevent  the  frequent  occurrence  of  the  laryn- 
geal congestion  in  individuals  predisposed  to  it,  by  taking  care  to  avoid  exposure  to  cold 
and  dampness. 

“ The  abnormal  susceptibility  of  the  larynx  should  be  combated  by  fomentations  of 
cold  water  upon  the  neck,  and  at  the  same  time  general  bathing. 

“At  the  commencement  of  an  attack  absolute  rest  should  be  enjoined,  the  use  of 
diaphoretics  to  keep  up  activity  of  the  skin,  and  the  use  of  emollient  gargles  and  inha- 
lations of  steam,  with  or  without  aromatics. 

“ If  the  case  is  very  severe,  a more  energetic  medication  is  advisable.  Hot  fomenta- 
tions and  application  of  tr.  iodine  externally.  If  necessary,  the  use  of  vesicants  should 
be  resorted  to,  applied  in  front,  over  the  larynx.  Leeches  may  often  be  applied  to 
advantage.  If  pain  is  very  severe,  applications  of  solution  of  muriate  of  cocaine  by 
means  of  a sponge  carrier  will  give  relief.  The  administration  of  salicylate  of  soda  is 
at  times  beneficial,  but  not  so  much  so  as  in  simple  rheumatism.  When  suffocation  is 
imminent,  tracheotomy  must  be  performed  as  the  only  means  of  avoiding  a fatal  ter- 
mination.” 

Of  the  chronic  rheumatic  laryngitis  to  which  I would  call  your  attention  I can  find 
no  mention  in  medical  literature. 

For  many  years  past  I have  from  time  to  time  observed  chronic  painful  affections  of  the 
larynx,  attended  by  no  erosions  or  ulcerations  and  by  but  little  congestion  and  swelling 
of  the  part.  At  first  I was  inclined  to  consider  these  merely  cases  of  neuralgia,  but 
several  years  ago  I became  convinced  that  they  were  not  all  of  neurotic  origin,  and 
during  the  past  two  years  several  similar  cases  have  been  under  my  care,  which  have 
confirmed  me  in  the  opinion  that  they  are  rheumatic  in  character. 

At  the  last  meeting  of  the  American  Laryngological  Association,  in  May  of  the  pres- 
ent year,  Dr.  S.  H.  Chapman,  of  New  Haven,  Conn.,  read  a paper  on  “ Myalgia  of  the 
Pharynx  and  Larynx,”  in  which  he  described  cases  that  seemed  at  first  similar  to  those 
to  which  I refer.  He  thought  them  to  have  been  caused  by  malaria.  A careful  perusal 
of  his  article  will  show  that  they  were  quite  different  from  the  cases  I would  term 
rheumatic. 

The  affection  to  which  I wish  to  direct  attention  usually  occurs  in  persons  of  a 


SECTION  XIII — LARYNGOLOGY. 


35 


rheumatic  diathesis,  but  ofteu  the  laryux  or  the  tissues  about  the  hyoid  bone  present 
the  only  evidence  of  the  constitutional  disease.  In  this  affection,  as  in  the  chronic 
rheumatism  of  a mild  character,  which  often  affects  the  joiuts,  or  as  in  muscular 
rhematism,  the  paiu  is  not  constant,  but  may  frequently  disappear  for  a few  days, 
especially  during  fine  weather,  to  return  again  on  slight  exposure  or  with  changes  in 
the  temperature.  Its  course  is  erratic,  but  nearly  always  obstinate.  The  patients 
frequently  have  an  inherited  or  acquired  predisposition  to  rheumatism,  and  it  is  not 
unusual  for  them  to  complain  of  rheumatic  pains  in  other  parts  of  the  body,  but,  singu- 
larly, they  never  suspect  the  true  nature  of  the  disease. 

Several  of  the  cases  I have  seen  have  complained  of  hoarseness  or  aphonia.  Most 
of  them  have  been  troubled  with  the  pain  for  several  months  before  coming  to  me,  and 
I have  usually  found  them  filled  with  apprehensions  of  cancer.  In  no  case  has  pain 
been  very  severe.  In  certain  cases  it  has  been  most  noticeable  on  using  the  voice,  but 
it  is  often  more  troublesome  when  swallowing,  and  in  some  it  is  aggravated  by  every 

■ attempt  at  deglutition,  even  of  saliva.  However,  it  varies  much  in  intensity  from  day 
I to  day  or  from  week  to  week,  being  nearly  always  worse  in  damp  or  chilly  weather. 

Patients  commonly  refer  the  pain  to  one  side  of  the  larynx  when  this  organ  alone 
is  involved,  but  in  some  cases  it  is  also  referred  to  the  trachea,  the  region  of  the  greater 
cornu  of  the  hyoid  bone,  to  the  base  of  the  tongue,  or  to  the  lower  part  of  the  tonsil  on 
the  corresponding  side.  In  similar  cases  we  sometimes  find  the  pain  confined  to  these 
• latter  regions,  there  being  little  or  no  involvement  of  the  larynx,  but  even  in  these  the 
i patient  is  liable  to  experience  fatigue  of  the  vocal  organ  after  talking.  Hoarseness  or 
loss  of  voice  are  also  frequent  symptoms.  Upon  inspection  of  the  parts,  one  or  both 
; arytenoids  may  be  slightly  congested,  or  the  redness  may  be  confined  to  one  side  of  the 
I fauces  or  to  the  pharynx.  The  vocal  cords  remain  clear,  and  the  inflammatory  symp- 
. toms  seem  altogether  inadequate  to  account  i'or  the  discomfort.  In  some  cases  the 
i parts  involved  are  slightly  swollen,  but  in  others  no  change  of  form  is  noticeable. 

The  diagnosis  of  chronic  rheumatic  laryngitis  must  be  based  on  the  history  and 
i symptoms,  and  the  exclusion  of  neuralgias  and  the  various  affections  which  cause 

■ organic  change  in  the  parts.  Acute  catarrhal  inflammations,  chronic  syphilitic  laryn- 

■ gitis  and  abnormal  growths  may  be  easily  excluded.  Tubercular  laryngitis,  in  its 
inception,  is  often  attended  by  fatigue  of  the  larynx  after  talking,  and  sometimes  by 

i paiu,  even  before  there  is  ulceration  or  swelling  ; but  it  has  a different  history  from  the 
rheumatic  affections.  In  tubercular  laryngitis  the  parts  are  usually  paler  than  in 
health,  while  they  are  slightly  congested  in  the  rheumatic  affection.  In  the  tuber- 
> cular  disease  the  constitutional  symptoms  are  marked  ; not  so  in  the  rheumatic. 

Fully  developed  tubercular  laryngitis  cannot  be  mistaken  for  the  affection  under 
. consideration. 

In  malignant  affections  of  the  larynx  pain  is  often  present,  but  from  my  observa- 
. tion  I conclude  that  it  does  not  often  precede  pronounced  organic  changes.  Therefore, 

' they  are  not  likely  to  be  confounded  with  the  affection  under  consideration.  Eheu- 
I matic  laryngitis  is  most  likely  to  be  confounded  with  neuralgia  or  paraesthesia  of  the 
i organ.  In  distinguishing  between  these,  the  history  must  be  carefully  scrutinized, 

I and  rheumatic  or  neuralgic  pains  must  be  looked  for  in  other  parts  of  the  body.  In 

■ the  rheumatic  affection  there  is  usually  slight  redness  and  swelling  ; not  so  in  neuralgia. 
For  confirmation  of  the  diagnosis,  we  must  sometimes  await  the  result  of  treatment. 

Rheumatic  laryngitis  usually  runs  a chronic  course,  extending  over  periods  varying 
I from  two  months  to  one  or  more  years.  In  most  cases,  if  not  in  all,  there  are  periods 
I of  immunity  from  the  soreness,  but  at  other  times  there  are  quite  severe  exacerbations 
of  pain.  I recall  one  case  which  was  troublesome  at  times  for  four  or  five  years. 
Recovery  may  be  expected  ultimately,  and  the  patient  may  and  should  be  assured  that 
; the  disease  does  not  endanger  life. 


3G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  the  treatment  of  chronic  rheumatic  laryngitis,  I have  derived  considerable  bene- 
fit from  the  local  application  of  stimulant  and  astringent  sprays,  or  pigments,  and  in 
some  cases  galvano-cauterization  of  the  congested  surface  seems  to  have  aided  much  in 
recovery.  However,  I have  relied  mainly  upon  internal  remedies  suited  to  the 
diathesis.  Iodide  of  potassium,  salicylate  of  soda,  guaiac,  colehicum  and  cimicifuga 
have  all  been  tried  with  more  or  less  success.  Extract  of  phytolacca  has  been  given 
with  apparent  benefit,  and  oil  of  gaultheria,  in  doses  of  fifteen  minims,  three  times  a 
day,  has  at  times  given  satisfaction. 

By  way  of  illustration,  I have  selected  from  my  note  books  records  of  a few  cases 
that  demonstrate  the  characteristics  of  this  affection. 

Case  I. — Mrs.  W.,  aged  thirty-two  ; general  health  perfect.  About  four  years  ago 
this  lady  complained  of  almost  constant  pain  in  the  larynx,  which,  however,  varied 
greatly  from  time  to  time.  Upon  examination  the  whole  throat  as  well  as  the  1 irynx 
was  found  congested  ; but  the  pharynx  was  so  exquisitively  sensitive  that  she  could 
scarcely  tolerate  inspection,  and  therefore  declined  any  local  treatment.  This  patient’s 
father  had  been  almost  a cripple  from  rheumatism  for  many  years  ; other  ancestors  had 
suffered  greatly  from  it,  and  the  patient  herself  had  frequently  been  subject  to  rheumatic 
pains,  but  at  the  time  referred  to  there  was  no  manifestation  of  the  disease,  excepting 
the  pain  in  the  larynx.  She  was  not  subject  to  neuralgia.  Anti-rheumatic  remedies 
were  ordered  and  taken  for  a short  time,  but  were  not  persisted  in,  as  she  had  lost  all 
faith  in  remedies  for  rheumatism,  excepting  the  waters  of  a certain  so-called  magnetic 
spring,  which  had  at  times  relieved  her  father. 

Whether  or  not  she  visited  the  spring  I do  not  know,  but  the  soreness  continued  at 
intervals  for  about  two  years,  when  it,  with  other  rheumatic  symptoms,  gradually  dis- 
appeared, and  she  has  since  been  perfectly  well. 

Case  ii. — Mr.  H.  G.,  farmer,  aged  forty -seven  ; general  health  good  ; but  he  was 
morbid  on  the  subject  of  cancer  of  the  throat.  He  had  been  complaining  for  two 
months  of  pain  and  sense  of  fullness  in  the  larynx,  which  he  feared  would  choke  him. 
The  soreness  was  not  constant,  but  would  come  on  quite  suddenly,  last  three  or  four 
days,  and  then  gradually  subside. 

The  sensations,  when  I first  saw  him,  were  referred  to  the  upper  part  of  the  left  side 
of  the  thyroid  cartilage.  When  the  attacks  were  at  their  worst  his  voice  was  husky, 
and  occasionally  he  had  been  aphonic  for  a short  time.  He  had  been  frequently  anuoyed 
by  muscular  rheumatism,  and  he  stated  that  he  felt  lame  and  tired  all  over  his  whole 
body  when  the  exacerbations  came  on. 

Laryngoscopic  examination  revealed  moderate  congestion  of  the  epiglottis  and  left 
wall  of  the  larynx,  with  very  slight  swelling  of  the  latter  ; also  very  slight  congestion 
of  the  vocal  cord,  but  nothing  more.  On  touching  the  parts  with  a probe  he  claimed 
that  the  sensitive  spot  was  either  on  the  inner  surface  of  the  left  wall  of  the  larynx,  or 
else  just  external  to  the  left  wing  of  the  thyroid  cartilage,  but  he  was  not  quite  certain 
which. 

I placed  the  patient  on  twenty-grain  doses  of  bromide  of  potassium,  four  times  a 
day,  and  fifteen-minim  doses  of  oil  of  gaultheria.  I also  applied  a sixty -grain  solution 
of  nitrate  of  silver  to  the  left  side  of  the  larynx.  Eight  days  later  it  was  noted  that  he 
was  almost  well,  and  was  to  have  returned  to  his  home,  but  the  soreness  had  reappeared, 
lower  down,  at  the  upper  portion  of  the  trachea.  During  the  next  few  days  the  pain 
shifted  to  the  larynx  again,  and  then  to  a point  beneath  the  sternum.  Sixteen  days 
after  I first  saw  him  he  returned  to  his  home,  free  from  pain,  with  directions  to  take 
iodide  of  potassium,  grains  vijss,  and  oil  of  gaultheria,  ffb  xv  three  times  a day.  I learu 
that  the  pain  returned,  subsequently,  from  time  to  time. 

Case  iii. — Miss  F.  G.,  aged  twenty-two  ; general  health  good.  Her  voice  had  been 
weak  l'or  four  years,  whenever  she  attempted  to  shout,  but  this  gave  her  no  special  dis- 


SECTION  XIII — LARYNGOLOGY. 


37 


comfort.  Fora  month  before  consulting  me  she  had  been  complaining  of  aching  in  the 
: tonsils,  larynx,  trachea  and  sub-sternal  region  whenever  she  used  the  voice  for  a few 
minutes.  The  soreness  was  always  worse  in  damp  weather.  Examination  of  the  larynx 
showed  paresis  of  the  right  vocal  cord,  which  moved  through  only  about  one-third  its 
normal  excursion,  but  there  was  neither  swelling  nor  redness. 

In  this  case  there  was  no  previous  rheumatic  history,  and  there  were  no  signs  in 
the  larynx  excepting  those  of  paresis. 

Her  principal  symptoms  were  of  only  a month’s  duration,  and  I therefore  concluded 
that  the  paresis  was  either  of  recent  origin,  or  that  it  had  nothing  to  do  with  the  present 
s attack.  She  complained  of  other  pains  which  seemed  rheumatic  ; she  had  always  been 
- worse  in  damp  weather,  and  under  the  influence  of  salicylate  of  soda,  acetate  of  potas- 
, sium,  and  oil  of  gaultheria  she  improved  rapidly,  so  that  I think  the  diagnosis  was 
i fairly  established. 

Just  as  I was  completing  this  paper  the  patient  returned,  after  several  months’ 
. absence,  complaining  of  severe  and  constant  pain  in  the  same  regions  as  before.  She 
had  been  free  from  pain  for  several  weeks  during  the  interim,  but  it  had  recently 
t.  returned  with  increased  severity.  No  abnormal  signs  could  be  seen  in  the  larynx,  even 
[ the  paresis  having  disappeared,  and  the  evidences  of  rheumatism  were  more  pronounced 
c than  ever  before. 

Case  iv. — Mr.  J.  C.  R.,  aged  thirty-nine.  Patient  complained  of  pains  in  the 
i shoulders,  chest  and  back  of  the  head,  and  of  aphonia  of  four  months’  duration.  He 
had  suffered  several  attacks  of  inflammatory  rheumatism,  and  had  been  frequently 
t,  troubled  with  slight  attacks  of  sore  throat.  General  health  good.  Weight,  pulse  and 
temperature  were  normal. 

On  examining  the  larynx  I found  bilateral  paralysis  of  the  lateral  crico-arylenoid 
muscles,  with  inability  to  close  the  glottis  on  attempted  phonation,  but  there  was  no 
congestion  or  swelling. 

In  this  case  the  pains,  and  possibly  the  paralysis,  seemed  to  be  of  rheumatic  origin. 
I saw  the  patient  only  once,  and  have  not  heard  the  result  of  treatment. 

Case  v. — Mr.  C.  F.  M.,  aged  twenty-nine.  General  health  perfect.  Had  complained 
of  soreness  of  the  throat  much  of  the  time  for  four  months,  of  occasional  hoarseness,  and 
of  rheumatic  pains  in  the  back  and  chest,  and  in  the  regions  of  the  trachea  and  hyoid 
bone.  These  pains  were  always  aggravated  by  damp  weather  and  by  exposure  to 
night  air. 

Under  the  influence  of  stimulant  applications  to  the  throat  and  anti-rheumatic 
remedies  internally  he  speedily  improved,  but  every  four  to  six  weeks,  with  some 
renewed  exposure,  his  symptoms  have  returned.  He  is  at  present  well,  but  I expect 
renewed  attacks. 

Besides  these,  several  other  such  patients  have  been  under  my  care,  and  I am  confident 
that  similar  cases  have  presented  themselves  to  other  laryngologists,  but  we  have  been 
accustomed  to  class  them  with  the  cases  of  neuralgia  or  paraesthesia,  with  no  very  defi- 
nite idea  of  their  etiology  and  but  little  hope  of  benefit  from  treatment. 

I am  confident  that,  with  more  critical  observation,  we  shall  find  many  cases  similar 
to  those  I have  described,  which  are  due  to  the  same  causes  as  muscular  or  articular 
rheumatism,  and  in  which  we  will  obtain  far  better  results  from  treatment  than  we 
have  been  accustomed  to  if  we  bear  this  in  mind,  and  prescribe  constitutional  remedies 
accordingly. 


DISCUSSION. 

Dr.  J.  A.  Stucky,  of  Lexington,  Ky. , remarked — This  Section  is  greatly 
indebted  to  Dr.  Ingals  for  the  timely,  practical  and  valuable  paper  just  read.  I 
have  no  doubt  but  many  of  us  have  had  cases  of  rheumatic  laryngeal  trouble  and 


38 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


failed  to  recognize  it.  I remember  of  having  only  one  case,  and  that  of  such  interest 
and  so  instructive  to  me,  I beg  leave  to  report  it.  Patient  was  a lady  aet.  26;  had 
been  bedfast  for  eleven  days,  I first  saw  her,  with  inflammatory  articular  rheumatism 
of  violent  form.  I was  called  to  see  her  on  account  of  pain  over  the  larynx,  sensi- 
tive to  the  touch,  and  patient  said  her  neck  pained  her  as  much  as  her  joints.  Deg- 
lutition and  phonation  were  very  painful.  The  laryngoscope  revealed  marked 
hyperaemia,  with  oedematous  swelling  of  right  arytenoid.  Epiglottis  slightly  cedem- 
atous.  A diagnosis  of  the  rheumatic  poison  affecting  the  laryngeal  muscles  and 
articulation  of  the  cartilages  was  made.  And  the  dose  of  anti-rheumatic  remedies 
was  increased  ; soothing  applications,  consisting  of  neutral  oleate  of  cocaine  in 
vaseline,  were  applied  at  short  intervals,  by  means  of  the  spray.  The  symptoms 
increased,  with  very  little  amelioration  of  the  pain  in  the  larynx,  and  by  the  four- 
teenth day  the  dyspnoea  was  so  urgent  that  tracheotomy  was  advised.  While  on 
my  way  to  my  office  for  the  instruments  to  perform  the  operation,  the  patient  died, 
whether  from  suffocation  or  heart  involvement  I am  not  able  to  say.  Since  then, 
whenever  a patient  complains  of  pain  in  the  laryngeal  region,  I look  out  for  rheu- 
matic troubles.  If  these  symptoms  are  detected,  the  line  of  treatment  is  easily 
decided  upon. 

Dr.  Stockton,  of  Chicago,  111.,  said — I think  Prof.  Ingals’  paper  very  timely, 
and  I am  very  glad  to  hear  it.  I have  met  with  a number  of  cases  that  I am  confi- 
dent are  rheumatic,  being  unwilling  to  class  them  as  neuralgic. 

Paper  by  Dr.  J.  A.  Stucky,  of  Lexington,  Ky.,  owing  to  his  paper  being 
destroyed  by  fire,  was  read  by  title.  “ Clinical  Report  on  the  Treatment  of  Laryn- 
geal Phthisis.  ’ ’ 


THE  DIAGNOSTIC  DIFFERENTIATION  OF  RECENT  TUBERCULOUS,  1 
SPECIFIC  AND  RHEUMATIC  LARYNGEAL  DISEASES. 

LA  DIAGNOSTIQUE  DIFFERENTIELLE  DES  MALADIES  LARYNGIENNES  RHUMA-1 
TIQUES  SPECIFIQUES,  ET  TUBERCULEUSES  RECENTES. 

DIE  DIFFERENTIALDIAGNOSE  DER  PRIMAREN  TUBERKULOSEN,  SPECIFISCHEN  UND 
RHEUMATISCHEN  KRANKHEITEN  DES  LARYNX. 

BY  DR.  E.  S.  SHURLY, 

Detroit,  Mich. 

The  differentiation  of  recent  tuberculous,  specific  and  rheumatic  disease  affecting  the  ] 
larynx,  as  we  all  know,  is  a topic  of  very  wide  range.  I shall  endeavor,  however,  to  3 
present  the  subject  as  concisely  as  possible,  by  confining  myself  rigidly  to  the  laryngeal  j 
region.  You  will,  therefore,  notice  the  omission  of  many  things  which,  were  time  aud  I 
circumstances  favorable,  might  be  included. 

While  there  is  much  similarity  in  the  symptomatology  of  the  three  diseases  whose  -1 
local  expression  we  are  about  to  consider,  there  is  that  variation,  in  even  typical  cases,* 
which  will  allow  very  often  of  distinction. 

Without  further  generalization,  I will  call  your  attention,  first,  to  the  laryngoscopic  I 
appearances,  second,  to  the  objective  symptoms,  and  third,  to  the  systemic  symptoms 
accompanying  the  three  diseases. 

Hyperaemia,  or  congestion  and  inflammation  of  the  laryngeal  mucous  membrane,  is, 


SECTION  XIII — LARYNGOLOGY. 


39 


of  course,  one  of  tlie  earliest  manifestations  in  each  of  the  conditions  under  considera- 
. tion,  unless  we  may  sometimes  except  phthisis.  In  recent  syphilis,  whether  secondary 
or  tertiary,  it  is  apt  to  be  diffuse  and  persistent,  the  color  varying  according  to  the 
individual.  In  phthisis,  although  a majority  of  cases  present  a paleness  of  the  mucous 
membrane,  yet  this  may  soon  be  succeeded  by  congestion  more  or  less  diffused.  In 
rheumatism,  when  the  hypersemia  is  general,  it  seems  less  intense  and  more  disposed 
( about  the  upper  larynx — especially  in  the  muscular  variety — constituting  so-called 
rheumatic  laryngitis;  while  in  the  arthritic  form  the  congestion  seems  to  take  place 
i at  first  along  the  lateral  wall  up  as  far  as  the  faucial  pillars,  either  in  streaks  or  quite 
diffused.  The  surface  is  not  granular,  as  is  the  case  sometimes  with  either  of  the  other 
i diseases. 

Anaemia,  the  opposite  condition,  rarely  occurs  in  recent  diseases  of  either  affection, 
excepting  phthisis,  unless  as  an  oedema,  which  may  then  accompany  either  syphilis  or 
rheumatism,  especially  the  latter,  if  an  active  inflammation  be  seated  in  one  of  the 
arytenoid  joints. 

Tumefaction,  or  infiltration,  either  quickly  or  slowly,  succeeds  congestion  in  tuber- 
culous laryugeal  phthisis,  although  not  always.  All  of  us  have,  I think,  met  with 
i cases  of  tuberculosis  where  the  tumefaction  was  quite  diffuse,  and  beginning  even  in  the 
lower  laryux,  which  seemed  more  like  real  hyperplasia  than  mere  infiltration.  Of 
i course,  when  the  characteristic  swelling  of  the  arytenoid  eminences  and  epiglottis — so 
i common  in  this  disease — is  present,  the  diagnosis  is  about  determined.  In  syphilis, 
either  secondary  or  tertiary,  when  recent,  the  tumefaction  comes  slowly,  while  the 
■ thickening  is  not  so  great  or  regular.  The  surface  may,  and  often  does,  show  a papular 
; character  and  very  uneven  surface,  but  when  certain  regions  of  the  submucosa  contain 
the  principal  exudation,  a careless  inspection  might  lead  one  to  regard  the  nature  of 
the  case  as  tubercular.  In  some  cases  of  rheumatism  and  gout — especially  the  latter — 
the  tumefaction  is  not  diffuse,  hut,  on  the  contrary,  distinctly  localized  at  the  posterior 
part  of  the  larynx  on  either  side,  according  to  the  arytenoid  joint  affected,  and  is  of 
such  consistence  in  subacute  or  chronic  cases  as  to  appear  like  an  organized  hyperplasia. 

! Later  on,  if  the  joint  undergoes  organic  change  or  perichondritis  supervene,  the  thick- 
ening becomes  firm  and  corrugated.  In  my  opinion,  it  is  very  difficult,  indeed,  in  such 
eases — early  stages — to  differentiate  between  a local  manifestation  of  syphilis  aud 
rhuematic  gout  or  gout. 

In  the  muscular  variety  of  rheumatism  the  tumefaction  is  usually  very  slight,  and 
1 disposed  in  lines  or  patches. 

Ulceration  soon  supervenes  in  recent  tuberculous  disease,  and  less  rapidly,  as  a rule, 
in  syphilitic,  while  never  in  rheumatic,  excepting  in  advanced  states  of  rheumatic 
: perichondritis. 

Regarding  syphilis,  it  is  considered  doubtful  by  many  observers  if  condylomata  or 
gummas  or  ulceration  ever  occur  in  the  larynx  early  or  primarily  ; while,  on  the  other 
; hand,  there  are  cases  reported  in  medical  literature  with  descriptions  of  such  appear- 
ances. When  ulceration  occurs,  it  comes  on  quickly  and  often  symmetrically ; the 
i ulcers  are  solitary,  deep,  with  sharp-cut  edges,  irregularly  round,  surrounded  by  a bright 
i areola  of  congestion  and  swelling,  and  having  a predilection  for  the  aryepiglottic  folds 
and  upper  surface  of  the  epiglottis.  It  is,  however,  very  rare  to  find  ulceration  in  recent 
syphilitic  disease  primarily  occurring  in  the  larynx.  The  ulceration  of  laryngeal 
phthisis  or  tuberculosis  comes  on  slowly.  It  is  more  apt  to  ‘occur  primarily  in  the 
larynx  than  in  the  structures  above.  The  ulcers  are  small,  numerous,  scattered,  super- 
ficial, edges  irregular,  in  some  cases  described  as  like  worm  tracks  ; while  in  others  they 
are  smooth,  oval  excavations,  generally  seated  on  the  under  side  of  the  epiglottis,  ary- 
tenoid and  aryepiglottic  folds,  ventricular  bands,  and  less  frequently  on  the  vocal  cords. 


40 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


It  has  been  said  that  tubercular  deposit  might  be  recognized  in  the  edges  of  the  ulcers 
of  some  cases. 

Of  course  there  are  many  departures  from  the  typical  appearance,  as,  for  instance, 
when  the  case  is  a mixed  one ; then  the  ulceration  may  be  rapid  and  serpiginous,  or 
deep  and  confluent,  even  in  the  early  stages.  I remember  a case  of  this  sort  in  my  own 
practice,  with  well-marked  ulceration,  confined  to  the  larynx,  and  with  a history  of 
both  tuberculosis  and  syphilis,  which  went  on  from  congestion  to  extensive  destruction 
of  the  laryngeal  membrane  in  two  weeks. 

Laryngeal  hemorrhage  is  rarely  a symptom  of  laryngeal  phthisis  or  syphilis, 
excepting  as  a result  of  erosion,  but  it  is  sometimes  an  accompaniment  of  rheumatism. 

The  mobility  of  the  parts  may  very  early  suffer  impairment  in  the  course  of  these 
diseases,  whether  syphilitic,  laryngeal  or  rheumatic.  Immobility  of  one  or  both  cords 
would  be  due  either  to  tumefaction,  hyperplasia  or  paralysis.  The  immobility  due 
to  rheumatism  can  be  easily  confounded  with  paralysis  or  immobility  from  totally 
different  causes,  as  when  a rheum-arthritis  affects  one  of  the  arytenoid  joints.  The 
distinguishing  feature,  aside  from  the  history,  in  cases  where  the  articulations  are 
involved,  is  the  location  of  swelling  or  fullness  toward  the  base  of  the  cartilage  and 
about  the  attached  portion  of  the  ventricular  bands,  together  with  the  pain  of  larynx 
and  neck  muscles ; and  when  the  laryngeal  muscles  are  the  seat  of  the  trouble,  the 
swelling  may  be  insignificant  and  the  mobility  be  incomplete,  but  the  pain  or  soreness 
is  excessive. 

The  objective  symptoms  belonging  to  the  early  stages  of  these  diseases  may  be 
mentioned  as  hoarseness,  aphonia,  dysphonia,  odynphagia,  dysphagia,  pain  in  the  throat 
and  adjacent  region,  cough,  secretion  and  expectoration,  varying  in  degree  according  to 
the  case.  Hoarseness  is  generally  present  in  laryngeal  hyperaemia  from  any  cause, 
unless  confined  to  the  upper  part  of  the  larynx,  and  is  due  either  to  functional  disturb- 
ance or  the  different  conditions  of  tumefaction  affecting  the  mucosa  or  submucosa  or 
the  interarytenoid  fold.  Though  generally  present,  it  is  not  invariably  in  recent  tuber- 
culous or  syphilitic  disease ; but  dysphonia,  especially  accompanied  by  soreness  of  the 
neck,  is  a marked  symptom  of  rheumatism.  In  gout,  however,  the  pain  and  soreness 
is  more  limited  and  less  fugitive  than  in  the  acute  or  subacute  variety  of  rheumatism. 
Cough  of  peculiar  character  is  almost  always  present  in  syphilis  and  laryngeal  phthisis, 
but  not  so  in  rheumatic  disease,  except,  perhaps,  the  occasional  attempts  at  clearing  the 
throat,  which  hardly  amount  to  laryngeal  cough. 

Waiving  any  remarks  upon  the  secretions  of  the  mucous  membrane  in  syphilitic 
and  tuberculous  disease,  with  which  all  are  familiar,  I would  state  that  in  rheumatic 
it  is  usually  a glairy  mucus,  excepting  in  gouty  cases,  associated  with  more  or  less 
bronchial  catarrh,  when  it  is  muco-purulent.  Microscopic  examination  of  sputum  never 
shows  bacilli  or  elastic  tissue,  excepting  in  cases  complicated  with  chronic  bronchitis  or 
phthisis. 

The  shortness  of  breath,  which  I have  seen  mentioned  as  one  of  the  signs  of  rheu- 
matic laryngitis,  occurs  only  in  those  cases  where  there  is  mechanical  obstruction  from 
tumefaction,  immobility  of  the  glottis  or  concomitant  bronchial  catarrh,  but  occasion- 
ally it  may  depend  upon  implication  of  the  muscles  of  respiration.  In  the  other  two 
affections  it  is,  of  course,  due  to  structural  changes.  Odynphagia  and  dysphagia  occur 
early  in  rheumatism,  but  later  in  syphilis  and  tuberculosis. 

Spasm  of  the  glottis',  while  occurring  at  times  in  laryngeal  phthisis  and  syphilis,  is 
much  more  frequent  in  the  early  stages  of  rheumatic  disease,  but  after  a time,  if  the 
disease  becomes  general,  this  symptom  disappears.  Chorea  of  the  vocal  cords,  or  paraes- 
thesia,  may  also  be  the  principal  symptoms  of  rheumatic  disease. 

The  clinical  history  connected  with  these  manifestations  is  certainly  an  important 


SECTION  XIII — LARYNGOLOGY. 


41 


, factor  in  the  diagnosis,  and  oftentimes  must  be  our  main  dependence  in  differentiation, 
i As  it  would  be  a matter  of  supererogation  as  well  as  a waste  of  time  to  enumerate  in 
detail  the  clinical  history  of  laryngeal  phthisis,  syphilis  and  rheumatism,  I will,  of 
i course,  pass  them  with  the  mere  mention. 

I am  fully  aware  that  the  existence  of  rheumatoid  disease  of  the  larynx,  as  well  as 
condylomata,  gummata  and  primary  tuberculous  deposit,  are  denied  by  many  competent 
observers ; hence  great  dissimilarity  of  ideas  attach  to  the  respective  terms  used  in 
giving  expression  to  these  various  local  appearances.  In  some  of  the  mixed  cases,  such 
as  present  a clinical  history  of  all  three  of  these  diseases,  differentiation  in  the  earlier 
: stages  becomes  almost  impossible. 

Concerning  the  rheumatic  affection,  which  is  not  as  common  as  the  others,  I think 
we  ought  to  recognize  two  varieties  at  least — the  one  a genuine  arthritis,  occurring  in  a 
gouty  subject,  perhaps  with  the  local  lesion  confined  to  the  neighborhood  of  the  joint, 
mainly  ; and  the  other,  seated  for  the  most  part  in  the  nervo-muscular  apparatus  of  the 
larynx,  and  also  affecting  the  neck  or  chest  muscles  more  or  less.  In  both  forms  the 
attending  pain  in  the  parts  and  neighborhood  is  apt  to  be  severe. 

In  conclusion,  permit  me  to  offer  a summary  in  the  form  of  a tabular  statement  of 
the  marked  signs  of  each  of  these  diseases. 


TABLE  SHOWING  PRINCIPAL  SIGNS  AND  SYMPTOMS  OF  RECENT 
TUBERCULOUS,  SYPHILITIC  AND  RHEUMATIC  DISEASE 
OF  THE  LARYNX. 


Laryngeal  Phthisis. 

Syphilis. 

Rheumatism. 

Hypercemia  or  congestion  often 
not  so  marked. 

Hypercemia  and  congestion  al- 
ways persistent  and  extended. 

Hyperoemia  and  congestion 
always  present  but  not  intense, 
and  often  localized. 

Tumefaction  or  infiltration 
quite  consta  nt  and  peculiar,  affect- 
ing epiglottis  and  arytenoids. 

Tumefaction  not  marked. 

Tumefaction  rare,  excepting  in 
arthritic  rheumatism,  when  it  is 
local. 

None. 

Condylomata  and  gummata 
sometimes. 

None. 

Ulceration,  common,  slow  de- 
velopment, scattered,  irregular, 
small,  roundish  or  oval,  commonly 
situated  on  under  surface  of  epi- 
glottis and  arytenoids. 

Ulceration  may  be  rapid,  but 
rare  in  larynx  ; when  occurring 
is  rapid  and  apt  to  he  solitary 
or  symmetrical,  surrounded  by 
areoia. 

No  ulceration. 

Mobility  o f cords  slightly 
affected. 

Mobility  slightly  affected. 

Mobility  out  of  proportion  to 
st ructu ra  1 change,  especially  arth- 
ritic variety. 

Hemorrhage  rare. 

Hemorrhage  very  rare. 

Hemorrhage  common. 

42 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


TABLE  SHOWING  PRINCIPAL  SIGNS  AND  SYMPTOMS  OF  RECENT 
TUBERCULOUS,  SYPHILITIC  AND  RHEUMATIC  DISEASE 
OF  THE  LARYNX. — Continued. 

OBJECTIVE  SYMPTOMS. 


Laryngeal  Phthisis. 

Syphilis. 

Rheumatism. 

Hoarseness. 

Hoarseness , dysphonia , slight. 

Dysphonia,  aphonia , or  hoarse- 
ness. 

Dysphagia  and  odynphagia  only 
when  epiglottis  and  arytenoid 
eminences  are  principally  affected. 

Not  marked,  unless  pharynx 
is  involved. 

Quite  persistent  and  constant. 

Pain  in  larynx  absent. 

Pain  in  larynx  absent. 

Pain  in  larynx,  quite  constant, 
and  about  neck. 

Expectoration  of  mucus  contain- 
ing bacilli  often. 

Expectoration  of  mucus,  no 
bacilli. 

Little  or  no  expectoration,  no 
bacilli 

Cervical  glands  not  enlarged. 

Cervical  glands  enlarged. 

Cervical  glands  not  enlarged. 

No  spasm  of  laryngeal  muscles, 
as  a rule. 

No  spasm  oflaryngeal  muscles. 

Spasm  frequent,  also  chorea. 

Sensation  not  perverted. 

Sensation  not  perverted. 

Sensation  often  perverted,  par- 
sesthesia. 

DISCUSSION. 

Dr.  Ingals,  of  Chicago,  El.,  had  been  much  interested  in  the  paper,  especially 
because  it  contained  much  on  rheumatic  laryngitis,  of  which  affection  very  little  could 
be  learned  from  medical  literature.  The  author  has  mentioned  some  points  which 
had  not  come  under  his  observation,  of  which  he  could  find  no  mention  in  medical 
literature. 

Dr.  Shurly,  in  closing  the  discussion,  remarked — I would  like  to  call  attention 
to  rheumatic  disease  of  the  larynx  because  Dr.  Ingals  says  the  literature  of  the  sub- 
ject is  meagre,  and  because  I believe  cases  of  this  sort  are  often  passed  as  laryngeal 
phthisis  or  other  diseases. 


THE  TREATMENT  OF  LARYNGEAL  PAPILLOMATA. 

LE  TRAITEMENT  DES  PAPILLOMES  LARYNGIENNES. 

UBER  DIE  BEHANDLUNG  DER  LARYNXPAPILLOME. 

BY  PROF.  W.  E.  CASSELBERRY,  M.D., 

Of  Chicago,  111. 

A discussion  of  the  treatment  of  laryngeal  papillomata  naturally  resolves  itself  into 
a consideration  of  the  best  means  of  eradicating  these  growths.  Their  removal,  by 
whatever  method,  has  been  much  facilitated  by  the  introduction  of  cocaine,  and  for  the 
sake  of  brevity  we  will  suppose  that  this  local  anaesthetic  be  applied  in  all  cases,  so  as 
to  permit  of  instrumental  manipulation  within  the  larynx.  The  laryngeal  forceps  are 


SECTION  XIII — LARYNGOLOGY. 


43 


commonly  employed  to  grasp  the  tumor  or  portions  of  it  and  cut  or  pull  it  from  its 
base.  A great  variety  of  these  have  been  devised,  of  which  those  of  Mackenzie, 
Schriitter,  Stoerk  and  Cusco  are  familiar  examples.  There  are  many  cases  in  which 
one  or  other  of  these  is  unquestionably  the  simplest  and  best  means  at  our  disposal. 
This  is  true  when  the  papilloma  is  single,  with  a narrow  and  circumscribed  base,  which 
is  not  too  deeply  inserted,  and  when  it  is  in  a position  accessible  to  the  forceps. 

There  are  other  cases,  however,  in  which  I am  convinced  the  forceps  are  not  only 
slow,  but  ineffective,  and  perhaps  even  worse  than  useless.  I have  in  mind  two  cases; 
in  one  the  papilloma  was  sessile,  flat,  with  a broad  base  covering  the  anterior  two-thirds 
of  the  superior  surface  of  the  right  vocal  cord  and  spreading  in  half  its  extent  around 
the  free  border  of  its  cord  on  to  its  inferior  surface.  I tried  forceps,  but  succeeded  in 
detaching  only  small  pieces  at  a time.  Each  operation  was  followed  by  inflammation, 
and  by  the  time  I could  again  operate  the  growth  was  as  large  as  before.  I despaired 
of  effecting  a cure  in  this  way.  It  was  like  pulling  pieces  from  a cutaneous  seed  wart  — 
the  more  I pulled,  the  faster  it  grew.  Moreover,  a part  of  the  tumor,  being  beneath  the 
vocal  cord,  could  not  be  reached  by  forceps. 

In  the  other  case  the  entire  larynx,  at  first  sight,  seemed  filled  with  papillomatous 
growth.  Forceps  were  used  to  clear  away  the  grosser  portions,  when  it  was  found  that 
the  warts  sprang  from  the  edges  of  both  vocal  cords  along  their  entire  extent  and  from 
the  inter-arytenoid  space.  They  had  a seedy  aspect,  i.  e.,  the  appearance  of  a common 
seed  wart  as  it  grows  on  the  hands.  Again  the  same  difficulty  was  encountered.  I 
could  not  by  means  of  forceps  exterminate  the  roots,  and  stimulated  apparently  by 
the  extraction  of  piece  by  piece,  their  growth  was  such  that  after  a certain  point  no 
progress  was  made. 

This  brings  me  to  another  method  of  removal — cauterization.  Rut  with  what? 
Nitrate  of  silver  is  too  superficial.  Chromic  acid  is  often  uncontrollable.  The  galvano- 
cautery  in  the  form  of  the  apparatus  which  I here  exhibit  answers  every  indica- 
tion. The  apparatus  is  Sajous’  handle  and  laryngeal  loop  electrode,  with  its  loop  bent 
to  one  side.  A perfect  cure,  with  restoration  of  voice,  was  effected  in  one  case.  In  the 
second  case,  restoration  of  voice  has  been  produced,  but  the  case  is  yet  under  treatment. 

A curette  has  been  devised  by  Dr.  Rossi,  of  Italy,  cited  by  Ferreri,  of  Rome,  the 
application  of  which  is  to  be  followed  by  scarification  of  its  base  and  cauterization  with 
a chemical  caustic.  I should  be  pleased  to  hear  this  method  discussed. 


DISCUSSION. 

Dr.  J.  Solis-Cohen,  of  Philadelphia,  referred  to  two  methods  of  removing 
laryngeal  growths  not  mentioned,  one  by  employing  the  snare  so  successfully  used  by 
the  Chairman,  and  the  simple  sponge  probang  by  means  of  which  white,  soft  growths 
can  be  nibbed  off  from  the  lower  surface  of  the  vocal  bands.  In  many  cases,  how- 
ever, it  is  necessary  to  incise  the  crico-thyroid  membrane  in  order  to  get  direct  access 
to  growths  in  that  position.  He  also  called  attention  to  a modification  of  the  jaws 
of  the  forceps  by  which  a broad  surface  is  supplied,  instead  of  the  pointed  end  of  the 
ordinary  oval  jaw,  which  facilitates  catching  hold  of  minute  growths  on  the  superior 
surface  of  the  vocal  bands. 

He  likewise  called  attention  to  the  importance  of  leaving  the  wires  of  the  electric 
cautery  as  thick  as  is  compatible  with  convenience  in  manipulation,  in  order  the  better 
to  confine  the  heat  in  the  platinum  terminal,  and  avoid  unnecessary  heat  in  the 
handle.  In  cauterizing  growths  on  the  edge  of  the  vocal  bands,  he  recommended 
protection  by  layers  of  asbestos  and  ivory  in  the  opposite  side,  so  as  to  avoid  injuring 
the  sound  tissues  in  the  sphincter-like  action  following  interference  in  the  larynx. 


44 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Prof.  E.  Fletcher  Ingals,  of  Chicago,  111. — Referring  to  the  statement  that 
chromic  acid  is  uncontrollable,  he  thought  there  could  be  no  difficulty  whatever  in 
controlling  its  action  if  it  were  fused  on  a probe  in  proper  quantity. 

Dr.  William  Porter,  of  St.  Louis,  Mo.,  uses  chromic  acid,  and  carefully  applies 
it  as  a safe  remedy.  The  curette  has  been  efficacious  in  two  cases,  and  the  sponge 
method  of  Yoltolini  in  one.  He  applies  the  chromic  acid  in  cases  of  small  growths 
where  it  is  difficult  to  apply  the  forceps.  He  uses  a probe,  on  which  is  fixed  a small 
glass  bulb  with  a depression  upon  one  side,  in  which  is  placed  a single  crystal  of 
chromic  acid. 

Mr.  Lennox  Browne,  of  London,  while  expressing  his  interest  in  the  cases 
considered  by  Prof  Casselberry,  who  had  initiated  the  discussion,  felt  some  regret 
that  the  field  of  debate  had  not  been  extended  to  consideration  of  the  important 
question  of  recurrence.  Without  doubt,  functional  abuse  of  the  voice,  and  a state  of 
chronic  and  persistent  hyperaemia,  were  main  factors  of  the  aetiology  of  papillomata ; 
and  in  certain  instances  in  which  the  hyperaemic  state  persisted  after  removal  of  a 
neoplasm,  there  would  be  a liability  to  recurrence,  not  necessarily  in  the  same  situa- 
tion, but  possibly  so,  or  in  some  other  part  of  the  larynx.  This  fact  constituted  a 
serious  element  of  consideration  when  forming  a prognosis,  and  accounted  for  the 
disappointment  often  experienced  by  the  operator,  who,  sometimes  having  cured  his 
patient  as  he  thought,  heard  of  the  case  coming  under  the  care  of  another  confrere 
as  uncured.  In  one  such  case  of  obstinate  recurrence  in  fresh  situations,  Mr.  Lennox 
Browne  had  experienced  a good  result  from  enjoining  absolute  silence  for  two  months, 
and  the  application  during  that  period  of  continuous  cold  over  the  larynx,  by  means 
of  a Leiter  coil. 

Prof.  W.  E.  Casselberry  closed  the  discussion  by  remarking — All  methods 
of  treatment  were  not  mentioned  by  me,  as  I expected  they  would  be  elicited  by  the 
discussion.  The  sponge  method  of  Voltolini  I have  not  tried.  The  snare  would 
have  been  inapplicable  in  the  two  cases  cited.  That  the  galvano-cautery  will  burn 
but  superficially  is  not  my  experience.  I think  it  can  be  made  to  burn  more  deeply 
than  other  caustics.  The  electrode  might  be  protected  on  one  side,  but  the  shield 
increases  the  bulk  of  the  instrument,  and  in  my  hands  has  not  been  necessary.  I 
have  not  searched  the  opposite  side  of  the  larynx,  because  I have  carefully  located 
the  part  to  be  cauterized,  pressed  the  electrode  into  it  and  away  from  the  opposite 
side  before  applying  the  current.  With  the  parts  thoroughly  cocainized  and  in  com- 
parative quietude,  I can  see  no  reason  why  the  galvano-cautery  should  not  be  used  as 
well  below  as  above  the  epiglottis;  although,  as  a matter  of  course,  it  must  be  by 
skillful  hands.  My  galvano-cautery  is  not  fickle,  but  quite  reliable,  if  kept  in  proper 
repair. 


SECTION  XIII — LARYNGOLOGY. 


45 


RECURRENT  HEMORRHAGE  OF  THE  UPPER  AIR  PASSAGES. 

L’HEMORRIIAGIE  RECURRENTE  DES  VOIES  RESPIRATOIRES  SUPERIEURES. 

UBER  RECURRENTE  BLUTUNG  DER  OBEREN  LUFTtVEGE. 

BY  WILLIAM  PORTER,  M.  D., 

Of  St.  Louis,  Mo. 

Mr.  President. — You  have  asked  me  to  speak  upon  a most  interesting  topic.  I 
will  not  attempt  to  present  it  fully,  but  rather  to  make  some  suggestions  along  which 
the  line  of  an  argument  may  run. 

First  let  me  limit  the  geographical  boundaries  of  the  term  upper  air  passages. 
Epistaxis  forms  the  subject  of  another  discussion,  and  we  will  not  include  that  at  this 
time.  Bronchial  hemorrhage  is  rare  except  as  a complication  of  pulmonary  involve- 
ment, and  when  found  is  discovered  by  the  use  of  the  stethoscope  rather  than  the  laryn- 
goscope —by  hearing  rather  than  by  sight. 

While  many  of  us  include  diseases  of  the  chest  in  our  field  of  work,  it  is  proper 
here  that  we  should,  as  far  as  possible,  confine  our  remarks  to  laryngological  topics 
only. 

Excluding,  then,  for  these  reasons,  epistaxis  and  hemorrhage  from  the  bronchial 
tubes,  let  us  turn  our  thought  to  recurrent  hemorrhage  of  the  larynx  and  pharynx. 
Again,  I think  we  need  consider  those  cases  only  in  which  the  hemorrhage  is  of  idio- 
pathic origin.  Interesting  essays  have  been  written  upon  such  themes  as  hemorrhage 
following  uvulotomy  (Morgan)  and  tonsillotomy  (Lefferts),  but  such  phenomena  as  these 
and  other  writers  upon  kindred  subjects  have  mentioned  can  scarcely  be  called  recurrent, 
but  rather  persistent  and  constant. 

Two  cases  may  be  used  as  illustrations  of  our  subject.  The  first  was  recurrent  hemor- 
; rhage  from  the  larynx. 

Miss  K.,  about  eighteen  years  of  age,  with  good  family  history,  consulted  me 
because  of  frequent  bleeding,  which  she  feared  originated  in  the  lungs.  She  had  had 
some  hoarseness  and  at  times  soreness  in  the  glottic  region,  but  not  constantly.  A careful 
examination  of  the  chest  did  not  enable  me  to  locate  the  lesion.  At  that  time  I could 
not  discover  any  abnormal  condition  suggesting  hemorrhage  in  the  upper  air  passages, 
although  there  was  a chronic  laryngitis  and  pharyngitis. 

A few  days  later  she  again  called.  She  had  been  bleeding  slowly  for  some  hours, 
and  was  still  expectorating  blood  at  intervals.  This  time  the  source  of  the  hemorrhage 
was  found.  A small  perforating  ulcer,  which  had  escaped  my  attention  at  first  exami- 
1 nation,  was  seen  on  the  right  ventricular  band,  and,  after  removing  all  the  exuded  blood 
i by  absorbent  cotton,  the  fresh  blood  could  be  observed  coming  from  the  ulcer.  A solu- 
tion of  iron  and  glycerine  promptly  controlled  the  hemorrhage.  There  was  recurrence 
of  the  hemorrhage  several  times,  and  the  ulcer  healed  slowly.  Rest  was  enjoined, 
phonation  restricted,  and  after  two  weeks  there  was  no  return  of  the  bleeding.  There 
t has  been  entire  absence  of  this  symptom  for  two  months,  and  the  laryngitis  under 
i treatment  has  improved,  though  not  entirely  relieved. 

Where  there  is  extravasation  of  blood  into  the  submucous  tissues  of  the  larynx, 
i serious  complications  may  ensue  and  death  may  quickly  occurfrom  obstruction.  One  of 
the  most  interesting  monographs  upon  this  subject  was  published  by  Dr.  Gleitsman  in  the 
1 American  Journal  of  the  Medical  Sciences,  April,  1885.  After  recording  a typical  case  of 
his  own,  he  mentions  a number  reported  by  others  (Mandl,  Fraenkel,  Lewin,  Hart- 
i man,  Wagner,  Jngals,  Knight,  Morgan).  Some  of  these  gentlemen  being  present,  will 
‘ doubtless  recall  the  cases  to  which  I refer. 


46 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Hemorrhage  from  the  larynx  is  not  a disease,  it  is  hut  a symptom,  and  must  he 
treated  as  such.  Generally  resulting  from  some  form  of  laryngitis  — simple  tubercular 
or,  in  rare  instances,  syphilitic — yet  a prominent  factor  in  its  production  may  he  a 
faulty  heart  action.  In  one  case,  at  least,  topical  applications  were  insufficient  until  the 
heart,  unable  to  do  its  work  through  mitral  lesion,  was  aided  by  rest  of  the  body  and 
digitalis. 

Hemorrhage  from  the  pharynx  may  easily  be  mistaken  for  haemoptysis.  In  1882  I 
reported  two  cases  to  the  American  Medical  Association,  in  the  Section  on  Laryngology. 
In  each  of  these  cases  there  was  some  slight  pulmonary  lesion,  and  when  the  hemor- 
rhage appeared,  it  was  but  natural  to  think  that  its  origin  should  have  been  in  the 
lungs,  and  in  each  the  true  site  was  in  the  pharynx.  Since  then  I have  seen  several 
similar  instances,  the  following  case  being  typical  : — 

Mr.  N.,  a young  attorney  of  St.  Louis,  having  had  during  previous  years  several 
attacks  of  bronchitis,  was  one  day  surprised  by  the  rapid  discharge  of  blood  from  the 
mouth.  He  was  sure  the  hemorrhage  came  from  the  right  middle  lobe,  where  he  had 
had  some  pain  during  the  attacks  of  bronchitis  mentioned. 

The  bleeding  had  ceased  when  I saw  him,  and  although  there  was  evidence  of  a 
slight  chronic  bronchitis,  the  percussion  note,  vesicular  murmur  and  rhythm  were  normal. 
Some  days  afterward,  Mr.  N.  again  came.  He  had  had  slight  bleeding  several  times 
during  the  day.  In  my  search  for  the  source,  I passed  a bent  cotton-covered  probe  into 
the  upper  pharynx,  and  was  rewarded  by  the  reappearance  of  the  hemorrhage,  the  blood 
trickling  down  from  behind  the  soft  palate. 

Suffice  it  to  say,  that  a small  ulcer  was  found  on  the  posterior  wall  of  the  velum, 
a little  to  the  right  of  the  median  line,  and  I need  scarcely  add  that,  with  this  dis- 
covery, all  fear  of  lung  complication  speedily  passed  from  the  patient’s  mind.  There  was 
no  further  hemorrhage,  the  ulcer  rapidly  disappearing  under  slight  treatment.  The 
thought  which  I would  offer,  in  submitting  these  condensed  histories,  is  that  hemor- 
rhage from  the  upper  air  passages,  is  not  infrequently  a complication  of  chronic  inflam- 
mation of  the  larynx  or  pharynx,  and  that  it  may  be  mistaken  for  haemoptysis  or  even 
haematemesis.  This  being  admitted,  in  all  cases  of  hemorrhage  from  the  respiratory 
tract,  of  doubtful  origin,  there  should  be  careful  examination  of  the  upper  air  passages. 


DISCUSSION. 

Prof.  Stockton,  of  Chicago,  111. , remarked — I wish  to  add  one  more  case  to 
those  already  reported.  A young  lady,  an  opera  singer,  one  day,  in  practicing,  sud- 
denly lost  her  voice,  and  in  a few  minutes  coughed  up  some  bright,  frothy  blood.  On 
examination  I found  the  larynx  coated  with  blood,  and  on  wiping  it  away,  I dis- 
covered a small  pulsating  vessel  from  which  hemorrhage  was  taking  place.  ‘I 
succeeded  in  controlling  the  flow  of  blood  by  the  galvano-cautery.  In  two  weeks’ . 
time  the  lady  was  able  to  sing. 

Dr.  J.  Solis-Cohen,  of  Philadelphia,  does  not  think  the  occasional  hemorrhages 
from  rupture  of  vessels  in  chronic  inflammations  of  the  larynx  and  pharynx  of  much 
importance,  and  has  never  seen  any  extreme  hemorrhage.  In  those  instances  in 
which  the  hemorrhage  is  submucous,  there  may  be  considerable  trouble  from  stridor, 
especially  in  that  of  oedema  of  the  larynx,  termed  hemorrhagic  oedema.  He  does  not 
approve  of  the  term  laryngitis  haemorrhagici,  sometimes  applied  to  these  conditions, 
and  does  not  use  the  term  himself 

Mr.  Lennox  Browne,  of  London,  desired  to  bear  testimony  to  the  value  of 
discussing  the  somewhat  uncommon  tut  important  class  of  cases  included  in  the 
interesting  communication  which  had  opened  this  debate.  Personally,  he  doubted 


SECTION  XIII — LARYNGOLOGY. 


47 


the  occurrence  of  laryngeal  hemorrhage  in  the  course  of  an  uncomplicated  laryngitis, 
and  would  always  give  a grave  prognosis  in  any  case  presented  to  his  notice.  Laryn- 
geal hemorrhage  was  not  a frequent  complication  of  tuberculous  laryngitis;  it  was 
more  common  in  his  experience  in  syphilis  than  was  believed  by  Dr.  Porter,  and  was 
one  of  the  causes  of  death  to  be  foretold  in  cases  of  laryngeal  or  rather  pharyngo- 
laryngeal  carcinoma.  A very  common  but  unrecognized  cause  of  slight  hemorrhages 
iu  the  throat  was  varix  of  the  vessels  at  the  base  of  the  tongue.  This  condition  was 
often  manifested  to  such  an  extent  as  to  constitute  a truly  hemorrhoidal  state  of 
affairs.  The  aetiology  was  in  many  respects  similar  to  that  of  rectal  hemorrhoids;  it 
was  often  associated  with  varix  in  other  parts  of  the  body,  and  required  for  successful 
j treatment  a local  eradication  by  electric  cautery  of  the  diseased  veins,  and  a careful 
• search  for  and  correction  of  all  general  and  functional  causes  that  might  have 
led  to  the  complaint. 

This  subject  was  one  which  had  been  treated  by  the  author  and  his  deceased  col- 
league, Llewelyn  Thomas,  at  Milan,  in  1880,  but  the  communication,  having  been 
somewhat  buried  in  the  Comptes  Rendus  of  that  Congress,  had  not  attracted  much 
notice.  It  was  fully  discussed  in  Mr.  Lennox  Browne’s  recently  published  new 
i edition  of  his  work  on  ‘ ‘ The  Throat  and  its  Diseases,  ’ ’ and  the  attention  of  the 
members  present  was  invited. 


48 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


THIRD  DAY. 


Meeting  called  to  order  at  11  a.m.  by  the  President. 

In  the  absence  of  Dr.  H.  H.  Curtis,  of  New  York,  Dr.  S.  N.  Benham  was 
appointed  by  the  President  to  read  Dr.  Curtis’  paper,  entitled — 

NASAL  STENOSIS. 

RETRECISSEMENT  NASAL. 

UBER  NASENSTENOSE. 

BY  H.  HOLBROOK  CURTIS,  M.D., 

Of  New  York. 

The  exact  function  of  the  nose,  from  a physiological  standpoint,  has,  as  yet,  not  been 
definitely  demonstrated,  though  great  advances  have  been  made  in  rhinology  since  5, 
the  last  meeting  of  the  International  Medical  Congress. 

The  important  relationship  between  pathological  conditions  of  the  olfactory  and 
respiratory  nasal  tracts  and  diseases  alfecting  their  continuity  in  the  pharynx  and 
larynx  well  deserves  the  amount  of  labor  and  research  which  has  been  devoted  to 
rhinological  laryngology  during  the  past  three  years. 

The  advent  of  intra-nasal  surgery  has  not  only  compelled  an  entirely  new  classifi-  ,j 
cation  of  nasal  diseases,  but  also  admits  of  the  elucidation  of  many  previously  obscure 
pathological  problems.  The  surgery  of  rhinology  had  its  origin  and  a greater  part  of 
its  development  in  the  United  States,  and  the  compliment  paid  by  Mr.  Lennox  Browne 
to  the  American  Laryngological  Association,  in  his  valuable  work  just  issued,  well 
shows  the  recognition  American  laryngology  obtains  abroad. 

The  various  deformities  of  the  bony  and  cartilaginous  framework  of  the  nose,  and 
their  surgical  relief,  together  with  the  altered  structure  or  function  of  the  turbinate  | 
bodies  and  their  mode  of  treatment,  will  illustrate  the  purport  of  this  thesis,  and  the 
title,  Nasal  Stenosis,  will  embrace  all  these  conditions. 

NASAL  STENOSIS  MAY  BE  OF  TRAUMATIC,  HYPERTROPHIC  OR  REFLEX  ORIGIN. 

1.  Traumatic  Stenosis  comprises  deviations  of  the  septum,  either  bony,  cartilaginous, 
or  both,  resulting  from  direct  injury,  improper  mode  of  lying  during  sleep  in  infancy,  j 
congenital  deformity  or  unequal  cranial  development. 

2.  Hypertrophic  Stenosis  includes  exostoses,  enchondroses,  thickened  ridges  along  one 
or  both  sides  of  the  septal  articulations,  hypertrophy  of  the  turbinate  bodies,  erectile 
tumefactions,  polypi,  neoplasms,  tumors,  etc. 

3.  Temporary  or  Reflex  Stenosis  includes  the  reflex  neuroses  and  those  conditions  in 
which  the  erectile  tissues  are  temporarily  enlarged,  either  by  increased  nutrition,  by 
vasomotor  paresis  or  by  irritation. 

The  term  Nasal  Stenosis  we  employ  in  its  generic  sense. 


SECTION  XIII — LARYNGOLOGY. 


49 


The  descriptions  of  diseases  under  the  names  “Post-Nasal  Catarrh,”  “Granular 
Pharyngitis,”  “Hypertrophic  Lateral  Pharyngitis,  ” etc.,  will  soon  he  done  away  with, 
and  the  near  future  of  pathological  research,  combined  with  better  physiological  kuowl- 
s edge,  will  cause  a reflex  impairment  of  function  in  these  cases  to  be  classified  as  such, 
rather  than  as  diseases  per  se. 

Post-nasal  catarrh  is  a symptom  of  nasal  stenosis,  so  also  is  ethmoiditis,  eustachian 
[.  catarrh,  otitis,  adenoid  growths,  pharyngitis,  laryngitis,  hay  asthma,  spasmodic  asthma, 
.enlarged  tonsils,  bronchitis,  etc.  When  we  say  bronchitis  we  do  not  include,  neces- 
sarily, all  bronchitis,  any  more  than  when  we  say  otitis  do  we  include  every  otitis;  but 
nasal  stenosis  includes  as  symptoms  some  of  the  above  conditions  in  a very  large  pro- 
! portion  of  cases.  Hence  the  relief  of  nasal  stenosis  becomes  an  essential  factor  in  the 
' treatment  of  these  conditions,  and  at  present  has  assumed  an  importance  in  laryngology 
not  dreamed  of  in  the  past. 

Some  of  the  best  literature  of  to-day — the  works  of  Mackenzie,  Cohen,  Lennox 
Browne,  etc.— dismiss  the  subject  of  deviation  of  the  septum  with  a page  or  two  in  five 
hundred,  and,  with  the  exception  of  Lennox  Browne,  make  but  passing  reference  to 
i stenosis  of  the  nostrils  from  so-called  hypertrophies  and  catarrhs  resulting  therefrom, 

1 while  to  thoroughly  cope  with  the  seriousness  of  the  trouble,  and  the  magical  effect  of 
the  restitution  of  the  lower  nasal  air  passages,  would  rightly  deserve  a quarter  of  the 
subject  matter  of  their  respective  works. 

The  study  of  stenosis  is  as  important  an  attribute  to  laryngology  as  the  consideration 
of  stricture  of  the  urethra  is  to  genito-urinology. 

For  several  years  the  writer  has  been  waiting  to  see  a case  of  “ Post-Nasal  Catarrh  ” 
unaccompanied  by  enlarged  turbinates  or  deviated  septum.  Writers  on  the  subject 
. maintain  that  the  catarrh  causes  the  erectile  tumefactions.  If  this  is  so,  why,  then, 
do  we  never  see  a catarrh  in  its  initial  stage  ? 

Rhinitis  is  a vasomotor  phenomenon,  with  its  stages  of  shock,  dilatation  and  secre- 
: tion.  Catarrh  may  result  from  chronic  rhinitis  only  when  the  dilatation  has  persisted 
long  enough  to  produce  oxygen  starvation  and  changed  secretion ; for  by  relief  of  the 
stenosis  and  reestablishment  of  free  oxygenation  the  altered  secretion  of  a catarrh  will 
lose  its  tenacity  and  become  normal.  A catarrhal  secretion  is,  then,  the  normal  secretion 
of  the  nostril  rendered  viscid  by  want  of  oxygenation.*  It  is  a matter  of  sincere  regret 
; that  certain  writers  have  made  of  late  rather  extraordinary  claims  for  their  ability  to 
j cure  all  conditions  of  catarrhal  implication  by  the  simple  procedure  of  sawing  off  the 
1 angle  of  a septal  deflection  or  the  free  use  of  chromic  acid  to  the  erectile  tissues  of  the 
1 turbinate  bodies,  without  taking  into  consideration  possible  ethmoidal  complications  ; 

for  the  writer  has  had  the  opportunity  of  seeing  several  cases  of  anterior  ethmoidal 
r.  catarrh,  periostitis  and  caries  which  have  preseuted  themselves  for  treatment  after 
i having  been  positively  assured  entire  freedom  from  their  symptoms,  following  a relief 
i of  nasal  stenosis.  It  seems  proper  to  consider  ethmoiditis  to  result  either  from  con- 
•I  tinued  colds,  causing  chronic  congestion  of  the  inter-ethmoidal  mucous  membranes,  or 
I from  stoppage  of  the  orifice  of  ethmoidal  secretions  by  pressure  f from  an  enlarged 
( turbinate  body.  There  is  no  doubt  that  many  so-described  catarrhal  conditions  of  the 
tantrum  are,  in  reality,  but  an  anterior  catarrhal  ethmoiditis.  The  condition  rarely 
I occurs  but  on  one  side.  It  is  frequently  seen,  but  I do  not  find  it  described  in  any 
text-book.  If  the  ethmoiditis  has  become  carious,  the  slender  probe  introduced  into 


* See  paper  by  writer,  read  before  Am.  Soc.  Sci.  Ass.,  and  published  in  American  Social 
Science  Journal.  Report  of  meeting  September  7th,  1886,  at  Saratoga. 

f See  paper  entitled  “A  Few  Points  Concerning  Laryngologieal  and  Rhinological  Work,”  read 
by  Dr.  II.  Holbrook  Curtis  before  the  New  York  Academy  of  Medicine.  ( New  York  Medical 
Record,  April  30th,  1887.) 

Vol.IV— 4 


50 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


the  anterior  orifice  of  the  ethmoid  cells  will  at  once  give  the  bony  touch.  This  is  done 
with  great  facility  as  the  result  of  a little  practice. 

It  is  due  to  the  apparent  lack  of  appreciation  of  the  existence  of  this  interesting  con- 
dition, that  the  differential  diagnosis  of  nasal  catarrhal  diseases  has  been  so  hopelessly 
at  fault,  and  though  it  does  not  directly  concern  the  subject  of  nasal  stenosis  (except 
when  it  occurs  from  hypertrophy  of  the  middle  turbinate  body  causing  pressure,  and 
retention  of  ethmoidal  secretions),  it  is  important  to  understand  the  difference  between 
an  ethmoiditis  and  a simple  nasal  catarrh. 

Having  outlined  the  principal  causes  of  nasal  stenosis,  and  touched  upon  the  symp- 
toms, let  us,  for  a moment,  take  up  the  consideration  of  the  traumatic  and  hypertrophic 
subdivisions. 

1.  Traumatic.  This  variety  occurs  as  deviation  of  the  nasal  septum  from  the  median 
line.  These  deviations  have  been  classified  by  the  writer  as — 

(а)  Vertical  (V). 

(б)  Horizontal  (H). 

(e)  Oblique,  ascending  and  descending  (OA)  (OD). 

(d)  Sigmoidal  (S). 

(e)  Pyramidal  (P). 

The  vertical  deflection  has  an  anterior  and  a posterior  plane,  with  the  line  of  the 
ridge  or  intersection  perpendicular  to  the  floor  of  the  nasal  cavity. 

The  horizontal  deflection  consists  of  two  planes  or  faces,  with  the  ridge  or  intersection 
parallel  with  the  floor  of  the  nasal  cavity. 

The  oblique  ascending  consists  of  two  planes,  the  ridge  or  intersection  rising  obliquely 
upward  and  backward,  usually  corresponding  to  the  line  made  by  the  articulation  of 
the  vomer  with  the  cartilage  of  the  septum. 

The  oblique  descending  ridge  will  make  either  an  acute  or  right  angle  with  this  line. 

The  sigmoidal  is  represented  by  a right  (or  left)  horizontal  deflection  in  the  middle 
meatus,  and  a left  (or  right)  horizontal  deflection  with  the  inferior  meatus  of  the  oppo- 
site side.  Sigmoidal  deflections  may  be  horizontal  or  vertical. 

The  pyramidal  deflection  presents  three  or  more  planes,  whose  apex  points  either  to 
the  right  or  left.  This  method  of  classification  has  been  adopted,  to  keep  a record  of 
operations  with  the  saw  or  nasal  trephine.* 

Thus,  if  an  operation  with  the  saw  or  trephine  has  been  performed  on  a nasal  deflec- 
tion of  the  septum,  we  write — 

It.  H.  D.  I.  M.  f in.  Trephine,  or, 

L.  P.  D.  M.  M.  Saw,  or, 

E.  V.  D.  total  occlusion,  Trephine  No.  3. 

In  other  words,  we  have  operated  with  the  trephine  on  a right  horizontal  deflection, 
which  caused  stenosis  of  the  inferior  meatus,  and  extended  for  two-thirds  of  an  inch. 

In  the  second  case  the  letters  express  an  operation  with  the  nasal 
saw,  on  a left  pyramidal  deflection  projecting  into  the  middle 
meatus. 

In  the  third  formula  we  read  that  a complete  stenosis  was  over- 
ly come  by  making  an  artificial  meatus  with  a T\  in.  trephine. 

It  will  be  seen  that  the  deflections,  except  the  sigmoidal  and 
pyramidal,  approximately  correspond  (considered  geometrically)  to 
the  diameters  of  an  octagon,  and  are  most  conveniently  referred  to 
in  this  manner. 


* See  paper,  “ The  Nasal  Trephino  and  its  Advantages,”  read  by  the  writer  before  the  Section 
of  Laryngology,  New  York  Academy  of  Medicine,  March  23d,  1S87. — A etc  York  Medical 
Journal,  May  28tb,  1887. 


SECTION  XIII — LARYNGOLOGY. 


51 


Tbe  deflections  we  are  most  frequently  called  upon  to  deal  w ' tli  are  cartilaginous  ; 
r they  usually  present  themselves  as  horizontal  or  oblique  ascending  in  the  anterior  nasal 
chambers. 

Next  in  point  of  frequency  occur  the  same  deflections  of  greater  extent,  with  bone 
in  the  posterior  portion.  Then  follow  in  order  of  frequency  of  occurrence  the  vertical, 

; pyramidal  and  sigmoidal.  The  oblique  descending  is  most  seldom  encountered. 

Rarely  do  we  find  a horizontal  deflection  which  implicates  the  posterior  border  of  the 
u vomer  ; and  bony  deflections  without  implication  of  the  cartilage  are  infrequently  met 
with. 

2.  Hypertrophic.— The  bony  exostoses  should  be  considered,  though  we  do  not  find 
many  cases  of  importance  ; occasionally  the  middle  or  superior  turbinated  bone  assumes 
an  arborescent  growth,  causing  pressure  in  the  adjacent  parts.  The  most  frequent  bony 

: growth  we  encounter  is  a spinous  process,  which  arises  from  the  superior  maxillary 
bone,  and  projects  into  and  causes  obstruction  of  the  inferior  meatus.  This  must  not 
> be  confounded  with  the  nasal  maxillary  spine,  which  is  frequently  seen  on  one  side. 

with  a dislocated  cartilage  in  the  other  nostril.  The  septum  immediately  at  its  origin, 

) at  the  anterior  floor,  often  becomes  thickened  by  cartilaginous  proliferation,  and  may 
- present  prominences,  the  size  of  a large  pea,  on  either  or  both  sides.  These  processes 
are  made  up  often  of  a union  of  osseous  and  cartilaginous  material,  of  the  same  con- 
3 sistency  as  the  ridges  above  alluded  to,  which  form  at  the  septal  articulations.  These 
;.  ridges  are  found  to  exist  most  frequently  in  the  noses  of  those  of  a rheumatic  or  gouty 
J diathesis,  and  are  generally  associated  with  enlarged  tonsils.  There  is  always  an 
i enlarged  turbinate  body  in  the  inferior  meatus,  obstructed  by  such  a tumor,  the  direct 
Tesult  of  the  anterior  stenosis.  The  tubercle  of  Zukerkandl  must  not  be  mistaken  for  a 
deflection  or  an  exostosis,  though  it  is  often  largely  developed,  and  errors  have  arisen 
from  its  appearance.  Far  more  often  than  the  septal  deflections  and  thickenings  do 
we  find  nasal  stenosis  to  result  from  enlargement  of  the  turbinate  bodies,  and  more 
especially  the  lower  turbinate.  This  enlargement  may  be  due  to  excitation  of  the 
erectile  tissues  for  a considerable  period,  as  we  observe  in  workers  in  acid,  wood  sawing 
and  metal  filing,  and  also  from  exposure  to  certain  dusts  and  pollens.  This  stimula- 
tion, as  with  snuff-takers,  goes  on  until  the  contractile  power  of  the  tissues  becomes 
lost,  and  we  have  a resulting  enlarged  turbinate  body,  either  soft  or  hard,  according  to 
the  amount  of  hyperplastic  metamorphosis  which  has  gone  on.  This  condition,  com- 
mencing with  a dilatation,  ends  in  true  hypertrophy.  These  hypertrophic  conditions 
are  seen  most  frequently  in  middle  life,  and  it  is  to  be  presumed  that  the  decreased 
nutrition  which  supervenes  on  the  development  of  true  hypertrophy  causes  later  a 
certain  shrinkage,  with  consolidation  of  the  material.  Some  nasal  irritants,  as  acid 
fumes  and  pollens,  tend  to  cause  a primary  excitation  of  the  erectile  tissues ; while 
others,  such  as  snuff  and  menthol,  cause  contraction.  But  whether  it  be  either  con- 
tinued dilatation  or  contraction  of  the  erectile  tissues,  the  secondary  effect  will  be  an 
hypertrophy,  as  evidenced  by  the  snuff-taker  and  the  patient  who  has  used  cocaine  for 
some  time  to  counteract  the  disagreeable  effects  of  a stenosis,  as  in  hay  fever. 

3.  Reflex. — Various  reflex  conditions  have  been  proved  to  be  the  direct  result  of 
hypertrophies  and  erectile  tumefactions  in  the  nostril ; and,  on  the  other  hand,  we  may 
find  the  nasal  erectile  mucous  membrane  to  be  acted  upon  and  enlarged  by  an  excita- 
tion or  irritation  of  a co-related  area.  In  the  female  the  erectile  tissues  ai'e  distended 
during  menstruation.  By  the  irritation  of  the  peripheral  ends  of  the  pneumogastric 
nerve  in  children  suffering  with  worms,  we  also  have  a nasal  excitation.  These  forms 
of  nasal  stenosis  are  not,  however,  origo  malorum,  and  do  not  require  our  attention  here. 

Symptoms. — Nasal  stenosis  causes  first  a diminished  air  current  in  normal  respiration, 
and  is  widened  by  a general  malaise  in  the  individual,  from  want  of  proper  blood 
oxygenation.  Sooner  or  later,  to  remedy  the  defect  of  improper  oxygenation  of  the 


52  NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 

pulmonary  air  tracts,  the  subject  becomes  a mouth-breather.  From  the  moment  a 
person  becomes  a mouth -breather,  two  diseases,  as  at  present  classified,  announce 
themselves;  viz.,  a subacute  catarrhal  rhinitis,  and  a subacute  pharyngitis,  afterward 
becoming  glandular.  These  in  course  maybe  complicated  with  subacute  laryngitis, 
Eustachian  catarrh,  bronchitis,  hypertrophy  of  the  tonsils,  adenoid  growths,  caseous 
degeneration  of  the  tonsils,  catarrhal  pulmonalis,  etc.,  etc. 

So  many  of  the  commonly  encountered  diseases  of  the  ear,  nose,  throat  and  lungs 
have  a symptomatic  association  with  nasal  stenosis,  that  it  would  be  almost  necessary 
to  include  an  index  of  throat  diseases.  Why  the  profession  at  large  do  not  and  have 
not  grasped  this  great  truth  is  surprising.  In  many  of  the  medical  schools  of  this 
country  the  examination  of  the  nasal  passage  is  untaught,  and  among  men  with 
acknowledged  ability  in  the  practice  of  their  profession,  in  New  York  City,  many  an 
error  in  diagnosis  is  corrected  in  the  offices  of  our  laryngologists.  It  seems  a disgrace 
to  scientific  teaching,  that  patients  suffering  from  a condition  as  apparent  as  nasal 
polypi,  or  almost  complete  stenosis  from  deflection  of  the  septum,  should  he  almost 
daily  advised  to  go  to  Colorado  or  Florida  to  avoid  phthisis.  More  good  will  be  done 
to  suffering  humanity  when  the  stethoscope  is  made  secondary  to  laryngo-rhiuoscopy  in 
the  investigation  of  pulmonary  affections.  While  briefly  stating  the  symptoms  of  nasal 
stenosis,  it  is  important  to  consider  the  fact  that  50  per  cent,  of  the  cases  which  present 
themselves  in  our  throat  and  ear  hospitals  are  fit  subjects  for  undergoing  an  operation 
for  the  relief  of  nasal  stenosis.  In  looking  over  the  reports  of  three  of  the  large  throat 
hospitals  in  London,  we  find  that  among  20,000  patients  treated  during  the  year  1886,  less 
than  one  patient  in  1000  was  operated  upon  for  deviation  of  the  septum,  and  with  t ie 
exception  of  one  institution,  viz.,  the  London  Throat  Hospital,  there  was  no  attention 
directed  to  the  use  of  escharotics  to  reduce  enlarged  turbinate  bodies.  At  the  London 
Central  Throat  Hospital,  where  Lennox  Browne  is  making  his  name  famous,  the  gal- 
vano-cautery  takes  the  place  of  chromic  acid,  but  the  work  accomplished  is  not  as 
thorough.  Woakes,  though  the  first  to  recommend  the  free  use  of  the  nasal  saw, 
seldom  employs  it  in  his  clinic.  It  is  easily  comprehended,  when  one  sees  the  thick- 
ness and  clumsiness  of  the  instrument,  as  compared  with  the  saw  of  Bosworth,  or  the 
even  more  delicate  saws  manufactured  for  the  writer,  and  known  under  his  name. 
Notwithstanding  the  brilliant  results  obtained  by  the  use  of  the  nasal  saw,  in  the  cure 
of  catarrhal  symptoms  from  stenosis,  nasal,  pharyngeal  and  laryngeal,  it  requires  some 
skill  to  properly  manipulate  the  same  in  order  to  produce  the  best  effects.  Two  distinct 
cuts  are  frequently  necessary,  and  the  angle  of  union  must  be  carefully  determined 
often  in  the  presence  of  considerable  hemorrhage.  The  saws  which  are  most  easily 
used,  are  the  long,  probe-pointed  but  very  thin  saws,  with  the  bayonet  handle  parallel 
to  the  blade,  the  teeth  on  the  upper  or  under  side,  as  one  wishes  to  cut  either  up  or 
down;  also  the  straight  knitting-needle  saw  with  double  teeth. 

These  three  saws  will  enable  one  to  do  all  the  work  necessary  upon  the  nasal 
septum,  the  needle  saw  being  useful  in  making  crescentic  cuts.  A very  large  experi- 
ence with  the  saw  has  taught  the  writer  that  the  region  of  the  inferior  meatus  is  the 
important  seat  of  operations,  and  in  many  cases,  the  reestablishment  of  the  lower 
channel  will  be  enough  to  give  relief  from  nasal,  pharyngeal  and  aural  troubles,  with- 
out attempting  to  reconstruct  the  entire  septal  anatomy.  For  those  whose  opportuni- 
ties for  operation  are  frequent,  and  time  is  an  essential  factor,  an  instrument  which  is 
vastly  superior  to  the  saw  is  the  nasal  trephine  of  the  writer,  operated  by  means  of  a 
flexible  cable  communicating  with  an  electric  motor,  water  motor,  or  revolving  wheel 
worked  by  an  assistant.  This  instrument  has  been  employed  by  me  for  several  months, 
to  the  exclusion  of  all  revolving  knives,  burr  drills,  etc.,  and  has  proved  extremely 
satisfactory.  By  means  of  the  nasal  trephine,  one  is  enabled  to  do  many  an  excavation 
to  relieve  astenosed  inferior  meatus,  when  the  ridges  appear  as  a thickening  to  which 


SECTION  XIII — LARYNGOLOGY. 


53 

oue  would  hardly  apply  the  saw,  on  account  of  the  difficulty  of  making  a good  opera- 
tion. The  instrument  has  been  thoroughly  described  by  me  in  the  New  York  Medical 
Journal  of  May  28th,  1887,  and  thus  i'ar,  with  a history  of  75  operations,  there  is  no 
i.  modification  which  I can  at  present  suggest.  To  any  one  who  has  had  the  continued 
j disappointments  with  the  stellate  punch  of  Steele,  and  Adams’  nasal  forceps,  that  the 
| writer  has  experienced  in  the  operation  of  septal  deviations,  the  trephine  must  he  hailed 
) with  delight.  With  trephines  of  this  kind,  varying  in  size  from  one-sixteenth  to  one- 
I iourth  of  an  inch  in  diameter,  one  is  enabled  to  do  an  operation  in  a few  seconds. 

which  by  other  methods  would  take  a much  longer  time.  The  free  use  of  cocaine 
; renders  the  operation  absolutely  painless,  bleeding  never  obscures  the  view  of  the 
operator,  and  the  result  is  always  better  than  when  the  saw  is  employed.  The  cut 
being  circular,  a concave  surface  results,  which  permits  more  space  than  when  a straight 
j -cut  is  made  with  the  saw.  It  is  possible  to  make  an  artificial  meatus  in  case  of  total 
occlusion  of  the  nostril,  where  the  saw  cannot  conveniently  be  introduced.  When  the 
i perforation  is  complete,  the  core  remains  within  the  cylinder  of  the  trephine,  and  is 
withdrawn  with  the  instrument.  Iu  regard  to  the  use  of  chromic  acid  for  the  treat- 
ment of  those  enlargements  which  occur,  either  as  the  result  of  a hypertrophy  of  the 
turbinate  bodies,  or  as  a dilatation  of  the  same  from  a lack  of  vasomotor  resiliency, 
I have  no  desire  to  retract  the  somewhat  criticised  assertion  made  by  me' in  a paper 
t read  before  the  New  York  Academy  of  Medicine  last  April,  in  reference  to  nasal  stenosis 
i from  turbinate  hypertrophies  or  enlargements,  in  which  I said  that  so  great  was  the 
importance,  iu  my  estimation,  of  a reestablishment  of  the  air  current  through  the  upper 
air  passages,  and  particularly  through  the  inferior  meatus,  iu  the  treatment  of  all 
affections  of  the  pharynx  and  larynx,  non-specific  or  non-tubercular,  that  I would  not 
exchange  the  flat  probe  aud  chromic  acid,  for  the  combined  douches,  sprays  and 
therapy  of  the  most  complete  laryngological  establishment.  There  has  been  much 
t comment  upon  the  claims  put  forth  for  chromic  acid,  but  those  who  are  adverse  to  it  are 
those  who  do  not  use  it  properly.  The  acid  should  be  permitted  to  remain  in  an  open- 
< mouthed  bottle  and  allowed  to  deliquesce;  a drop  of  glycerine  or  a few  drops  of  water 
i arrests  this.  The  partially  deliquesced  acid  should  be  reduced  to  a pulpy  consistency, 
i containing  fragments  of  the  crystals,  by  rubbing  up  with  a glass  pestle.  The  thick  mass 
t is  then  spread  upon  one  side  of  a flattened  copper  applicator  aud  introduced.  A good 
I rule  to  observe,  is  to  only  apply  the  acid  to  the  pendulous  portion  of  the  turbinate  bodies, 
i being  careful  not  to  touch  the  septum  or  floor  of  the  nasal  cavities;  disagreeable  symp- 
i toms  often  follow  if  the  soft  palate  is  touched. 

Much  more  frequently  are  we  called  upon  to  treat  in  this  manner  erectile  dilatations 
than  true  hypertrophies,  our  aim  in  these  cases  being  to  produce  a cicatricial  bandage 
i for  the  dilated  erectile  structure.  That  the  turbinate  bodies  possess  a normal  erectile 
function  is  conclusively  proven,  but  the  word  hypertrophy,  used  to  express  au  altered 
I condition  of  this  function  without  hyperplastic  deposit,  is,  in  my  opinion,  a misnomer 
The  presence  of  a true  hypertrophy  is  ascertained  by  the  application  of  cocaine  and 
chromic  acid,  neither  of  which  contracts  the  hypertrophied  turbinate  body,  but  either 
drug  causes  the  dilated  plexus  to  contract  at  once.  A true  hypertrophy  often  needs 
the  trephine  for  its  removal ; it  is  hard  and  gristly  to  the  probe  touch,  and  is  difficult 
of  removal  by  chromic  acid,  and  also  with  the  galvano-cautery.  Such  a condition  is  of 
rare  occurrence,  though  under  the  name  of  hypertrophies  are  generally  described,  in  the 
current  text-books,  simple  dilatations,  which  I have  termed  erectile  tumefactions,  in 
contradistinction  to  the  true  hypertrophies.  An  important  point  to  be  observed,  also, 
in  the  use  of  chromic  acid,  is  never  apply  enough  to  allow  of  its  running.  In  my  own 
practice  I take  a common  copper  wire,  No.  14,  about  six  inches  in  length,  and  flatten 
one  end  for  about  one  inch.  The  acid  is  then  smeared  on  one  face  of  the  flattened 
surface  ; the  application  is  introduced  to  about  the  middle  portion  of  the  lower  turbinate 


54 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


body,  and  applied,  as  it  is  withdrawn,  with  a gentle  brush  motion.  If,  now,  the  erectile  i 
tumefaction  is  well  shrunken,  and  the  surface  is  seen  to  be  well  “ burned,”  we  may  1 
again  anoint  the  applicator,  and  if  we  have  observed,  by  rhinoscopic  examination,  I 
slight  tumefactions  on  either  side  of  the  septum  or  posterior  border  of  the  turbinate  j 
bodies,  they  may  be  likewise  “burned.”  Cocaine  should  be  applied  before  we  use  the  j 
acid  and  the  application  becomes  painless.  Unlike  the  action  of  the  galvano-cautery,  j 
there  is  severe  pain  often  following  the  use  of  chromic  acid,  and  ofttimes  accompanied  i 
by  a slight  depression,  which  has  been  wrongly  described  as  chromic  acid  poisoning. 

It  must  be  remembered  how  frequently  we  witness  such  a depression  following  uvu-  ] 
lotomy,  more  from  an  acute  inflammation  in  the  vicinity  of  ganglionic  centres  than 
from  absorption  of  morbific  products.  After  the  chromic  acid  has  remained  in  situ  for 
some  minutes,  and  before  the  patient  has  been  allowed  to  blow  the  nose,  it  is  desirable  j 
to  spray  the  nostrils  with  a Dobell  solution,  and  to  keep  this  up  two  or  three  times  a 
day  until  the  sloughs  detach  from  the  turbinate  bodies.  The  absolute  relief  of  nasal 
stenosis  occurs  when  under  no  condition  there  can  be  contact  of  the  turbinate  bodies 
with  the  septum. 

When  the  superior  meatus  is  thoroughly  free  the  middle  meatus  will  in  most  cases 
follow  suit,  for  it  is  principally  by  a deflection  of  the  air  current  to  the  middle  meatus 
which,  a priori,  has  produced  there  the  congested  condition  of  the  turbinate  body  and 
contact  with  the  septum.  There  is  no  erectile  tissue  in  the  middle  turbinate  body,  and 
enlargements  of  these  are  neoplasms  or  true  hypertrophies. 

The  tissues  of  the  middle  turbinate  bodies  never  shrink  up  upon  pressure  from  a 
probe,  as  one  frequently  sees  even  in  youug  children  upon  making  slight  pressure  on 
the  anterior  erectile  structures  of  the  inferior  turbinate  bodies. 

Chromic  acid  alone  has  been  spoken  of  in  the  treatment  of  turbinate  stenosis, 
because  it  has  advantages  over  all  other  means.  The  galvano-cautery  is  not  as  certain 
of  accomplishing  as  much,  as  the  effect  is  over  on  the  withdrawal  of  the  electrode,  and 
to  do  sufficient  work  we  must  of  necessity  greatly  alarm  our  patient.  I have  tried  both 
methods,  and  the  patient’s  evidence  is  immensely  in  favor  of  chromic  acid.  NasaL 
surgeons  have  been  accused  of  giving  too  little  attention  to  therapeutics,  and  here  I 
take  occasion  to  give  my  evidence  in  favor  of  treating  any  stenosis  of  the  third  subdivi- 
sion, temporary  or  reflex,  by  doses  of  arseniate  of  strychnine,  phosphide  of  zinc,  aconi- 
tine, digitaline,  etc. 

This  class  of  cases,  however,  seldom  reach  the  specialist  until  they  have,  by  an 
enervation  of  the  vasomotor  centres,  entered  the  class  of  permanent  dilatation  and 
demaud  local  treatment. 

For  patients  to  whom  I have  made  applications  for  simple  dilatation  I always  pre- 
scribe a course  of  tonic  treatment  against  recurrence;  otherwise,  there  will  be  a return 
of  the  trouble  within  the  following  six  months,  which  will  necessitate  another  applica- 
tion of  the  acid.  To  sum  up:  the  relief  afforded  to  the  various  pharyngeal  and  laryn- 
geal troubles  by  the  simple  operative  procedures  necessary  to  overcome  a nasal  stenosis 
would  take  a volume.  I will,  however,  close  my  paper  by  citing,  in  as  few  words  as 
possible,  some  illustrative  cases  : — 

Case  i. — C.  W.  A.;  November  6th;  age  eighteen;  121  pounds. 

History. — Nasal  catarrh;  dry  throat  in  morning;  insomnia;  constant  cough;  deafness 
on  left  side;  tinnitus,  not  constant. 

Examination. — Nasal  stenosis,  L.  H.  D.;  glandular  pharyngitis;  bronchitis.  Watch: 

R.  32  ins. ; L.  4 ins. 

Treatment. — Op.  Saw.  L.  H.  D. ; chromic  acid  R.  I.  T.  and  L.  I.  T. ; Politzer  infla- 
tion and  cleansing  spray  daily.  (12  office  visits.) 

Result. — January  3d,  Watch:  R.  42  ins.,  L.  22  ins.;  cough  and  insomnia  cured;  no 


- - " 


SECTION  XIII — LARYNGOLOGY. 


i trouble  from  catarrh  ; glandular  pharyngitis  entirely  disappeared;  no  longer  a mouth 
breather;  weight  124  lbs. 

Case  ix. — A.  R.  B. ; November  12th;  clerk;  age  forty-five. 

History. — Catarrh;  headaches;  nightmares;  nervousness;  cannot  read,  011  account  of 
t restlessness;  vertigo  during  working  hours. 

Examination.  —Stenosis  R.  I.  T.  and  L.  I.  T. ; erectile  tumefactions;  subacute  pha- 
I ryngitis. 

Treatment. — Chromic  acid  to  R.  and  L.  I.  T.,  at  weekly  intervals  ; hygiene;  brom- 
hydrate  of  quinine;  cleansing  spray. 

Result. — January  12th,  patient  reported  himself  well  and  had  gained  eight  pounds 
• in  weight. 

Case  hi. — C. ; actor;  age  forty-one  years;  182  pounds  ; robust. 

History. — Had  “been  off”  for  a year;  voice  never  lasted  more  than  ten  days;  had 
been  treated  with  strong  astringents  daily  for  several  months;  severe  catarrh  and  ten- 
dency to  clear  throat  after  a few  words. 

Examination. — Vocal  resonance  muffled;  pitch  lowered;  could  use  low  middle  regis- 
ter, but  broke  on  higher  speaking  tones;  stenosis  R.  complete,  L.  slight;  R.  V.  D. 
L.  I.  T.  tumefaction;  glandular  pharyngitis;  chronic  laryngitis;  rosy,  fibrillated  cords. 

Treatment. — Saw,  R.  V.  D. ; chromic  acid  L.  I.  T.  and  R.  I.  T. 

Result. — One  year  has  passed,  and  since  restitution  of  nasal  breathing  has  not  been 
' “off  ” a night,  though  playing  constantly, 

Case  iv. — A.  P. ; actress;  aged  thirty;  robust. 

History. — Singing  voice  becoming  uncertain;  constant  sore  throat;  takes  cold  easily; 
throat  a source  of  constant  worry;  cannot  rest,  as  engagements  made  for  season;  oppres- 
sion on  chest;  travels  continually. 

Examination. — L.  P.  D.  almost  complete  stenosis;  R.  I.  T.  tumefaction;  inflamed 
pharynx  and  larynx. 

Treatment. — Saw,  L.  P.  D. ; chromic  acid;  R.  and  L.  I.  T. 

Result. — Seven  months  after  operation:  Voice  has  been  in  excellent  condition;  has 
not  caught  a cold  nor  had  an  attack  of  tonsillitis  since  the  operation. 

Case  v. — C.  B.  C. ; bank  cashier;  age  forty-six. 

History. — Spasmodic  asthma  for  eight  years;  never  can  go  up  stairs;  obliged  to  use 
horse  cars  instead  of  elevated  roads;  always  sleeps  in  an  easy  chair;  has  not  been  in 
i bed  and  slept  lying  down  in  five  years;  exhaustion  on  slight  exertion;  constant  cough, 
with  clear,  gelatinous,  starchy  expectoration;  frequently  casts  of  smaller  bronchi  are 
i expectorated;  very  emaciated. 

Examination. — Antemia;  total  R.  and  L.  stenosis;  R.  and  L.  H.  D.  polypi;  R.  and 
L.  I.  T.  hypertrophied;  pulse  120;  respiration  42;  temperature  98;  weight  129  pounds. 

Treatment. — R.  L.  H.  D.  trephined;  chromic  acid  R.  and  L.  I.  T. ; posterior  fibroid 
tumor  R.  I.  T.  snared ; polypi  snared ; deep  inhalations  of  iodoform  in  ether  spray  daily ; 
milk,  three  quarts  daily,  in  addition  to  unrestricted  diet;  digitaline,  quinine  and 
strychnine;  treatment  persisted  in  for  two  months. 

Result. — -Sleeps  all  night,  with  mouth  closed;  asthma,  except  slight  symptoms  on 
catching  cold,  cured  ; pulse  and  respiration  normal;  after  six  mouths,  weight  154 
pounds. 

The  above  patient  presented  himself  in  my  office,  supported  by  two  attendants, 
under  the  impression  that  his  lungs  were  the  seat  of  his  troubles,  and  had  long  been 
treated  under  that  assumption.  Notwithstanding  some  apprehensions  of  collapse,  I 
immediately  trephined  both  H.  D.  of  the  inferior  meatus,  and  relieved  him  of  some 
polypi,  leaving  two  hard  nasal  catheters,  9 English,  in  situ  for  the  day.  Then  followed 
a series  of  operations  with  the  saw,  trephine  and  snare,  requiring  several  weeks  of 
attendance  once  in  every  three  days. 


56 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


This  case  must  be  regarded  as  typical,  in  exhibiting  a complete  stenosis  and  the 
systemic  derangement  therefrom.  There  can  be  no  artificial  oxygenation  from  medi- 
cation that  will  so  rapidly  overcome  an  anaemia  as  the  reestablishment  of  the  nasal 
respiratory  tracts. 


THE  USE  OF  RESORCIN  (C6H4(H20)2)  IN  THE  TREATMENT 
OF  NASAL  CATARRH. 

L’USAGE  DE  LA  RESORCINE  DANS  LE  TRAITEMENT  DU  CATARRHE  NASAL. 
UBER  DIE  ANYVENDUNG  DES  RESORCINS  IN  DER  BEHANDLUNG  I)ES  NASENKATARRHS. 

BY  A.  B.  THRASHER,  M.A.,  M.D., 

Cincinnati,  Ohio. 

The  marked  natural  action  of  resorcin  as  a reducing  agent  has  been  pretty  well 
demonstrated  in  diseases  of  the  skin  where  there  is  infiltration  of  the  corium. 

It  causes  a shrinking  or  contraction  of  the  epithelium  so  as  to  produce  a true  corni- 
fication  of  this  layer.  The  deeper  tissues  are  affected  by  the  contraction  of  the  blood 
vessels  and  a consequent  stoppage  of  the  nutritive  supply  of  these  parts.  The  experi- 
ence of  Professor  Unna,  of  Hamburg,  seems  to  indicate  that  this  contractile  effect  lasts 
for  a long  time,  and  may  be  due  to  the  absorption  of  oxygen  from  the  histological  ele- 
ments of  the  tissues  and  vessels.  This  active  affinity  for  oxygen  may  also  explain  the 
very  powerful  anti-mycotic  action  of  the  drug.  The  brilliant  results  attained  in  the 
treatment  of  parasitic  diseases  of  the  skin,  notably  herpes  tonsurans,  by  Ihle,  of 
Leipsic,  indicate  that  resorcin  acts  not  only  by  reducing  inflammatory  conditions,  but 
also  that  it  is  a powerful  specific  antiseptic.  From  Ihle’s  report*  it  appears  that  resorcin 
penetrates  the  skin  deeply  and  destroyes  the  spores  which  have  extended  into  the  hair 
follicles. 

Having  the  physiological  action  of  the  drug  thus  pretty  well  demonstrated,  it 
occurred  to  me  to  try  its  action  in  certain  forms  of  nasal  catarrh. 

There  is  a very  obstinate  rhinitis  where  the  hypertrophy  is  uot  great  and  the  oedema 
is  considerable,  where  the  acute  stage  has  passed  and  the  hypertrophy  is  not  yet  suffi- 
cient to  occlude  the  lumeu  of  the  naris.  The  patient  comes  to  the  physician  wit)*  the 
story  that  he  “takes  cold  ” very  easily,  and  his  nose  is  stopped  up  at  night.  Sometimes 
but  one  side  is  occluded,  and  then  both,  or  more  frequently  the  stoppage  alternates  from 
one  side  to  the  other.  Questioning  will  generally  elicit  the  information  that  at  night 
when  the  patient  lies  on  the  right  side  of  the  body  the  right  side  of  the  nose  is  stopped, 
and  “vice  versa.”  Examination  of  the  nose  usually  reveals  both  nares  more  or  less 
well  open.  If  there  is  a closure  of  either  or  both  sides  a spray  of  two  per  ceut.  solution 
of  hydrochlorate  of  cocaine  will  cause  it  to  open  in  a few  minutes.  It  is  in  this  condi- 
tion that  I have  found  resorcin  of  signal  benefit. 

The  use  of  acids  or  the  gal vano -cautery  or  the  snare  will  quickly  remove  the 
hypertrophy  and  cause  the  most  urgent  symptoms  to  subside.  But  it  leaves  over  a 
greater  or  less  surface  scar  tissue  instead  of  the  normal  nasal  mucous  membrane. 
Resorcin  accomplishes  the  same  result  as  far  as  the  subsidence  of  troublesome  symptoms 
is  concerned,  and  the  nasal  mucosa  remains  intact  and  is  still  capable  of  fulfilling  its 
normal  functions. 

Given  a case  as  described  above,  aud  the  daily  application  of  a solution  of  resorcin 


SECTION  XIII — LARYNGOLOGY. 


57 


will  cause  a whitening  and  shrinking  of  the  swollen  membrane,  and  a marked  decrease 
in  the  action  of  the  over-active  mucous  glands.  The  effect  is  somewhat  similar  to 
; cocaine,  with  this  difference,  viz.,  whereas  cocaine  acts  rapidly,  and  its  action  is  over 
in  a short  time,  resorcin  acts  more  slowly,  and  its  action  extends  over  a very  much 
i greater  length  of  time. 

The  vehicle  employed  by  me  in  its  application  has  been  either  vaseline  or  olive  oil, 
and  the  strength  of  the  solution  varying  from  two  per  cent,  to  ten  per  cent.,  in  accord- 
ance with  the  amount  of  hypertrophy  and  the  irritability  of  the  membrane. 

I first  cleanse  the  mucous  membrane  thoroughly  by  throwing  a coarse  spray  of  the 
i following  solution  : li . acidi  borici,  sodii,  biboratis,  a a drs.  ij  ; 01.  gaultheriae,  gtt.  ij  ; 

Aqute,  Oj.  Misce.  Then  the  mixture  of  resorcin  is  put  in  an  atomizing  tube  having  a 
j large  aperture,  warmed,  and  the  nasal  mucous  membrane  drenched  with  the  spray. 
The  remedy  is  applied  for  the  first  week  daily,  to  the  cleansed  mucous  membrane. 

After  the  first  week  the  nasal  atomizer  every  second  or  third  day,  and  on  other 
days  the  patient  uses  an  ointment  (two  to  four  per  cent,  of  resorcin  in  vaseline),  apply- 
ing it  to  the  nasal  mucous  membrane  by  means  of  a small  camel’s-hair  brush. 

My  notes  on  forty  cases  treated  in  this  way  show  that  ten  were  dismissed  cured  in 
three  weeks,  fifteen  in  four  weeks,  seven  in  five  weeks,  four  in  six  weeks,  and  three  in 
two  months.  One  obstinate  case,  where  exacerbations  were  frequent,  and  which  would 
tolerate  only  the  weakest  solution  of  the  drug,  seemed  not  to  be  entirely  well  at  the  end 
of  twelve  weeks’  treatment. 

These  cases  were  all  essentially  chronic,  having  had  symptoms  of  stenosis  and  an 
excessive  muco-purulent  discharge  from  one  to  ten  years.  Some  of  these  patients,  since 
their  discharge,  have  returned,  with  attacks  of  acute  coryza,  which,  however,  have 
I readily  yielded  to  the  usual  treatment  given  such  cases.  In  summing  up  my  experience 
with  resorcin  in  the  treatment  of  nasal  catarrh,  I would  say  : — 

1.  It  is  most  useful  in  chronic  nasal  catarrh  accompanied  by  oedema  of  the  mucous 
i membrane  without  much  hypertrophy. 

2.  These  cases  are,  as  a rule,  cured  in  from  three  to  six  weeks. 

3.  Resorcin  should  be  used  daily  in  from  two  per  cent,  to  five  per  cent,  solution  in 
; vaseline  or  olive  oil  as  a spray  or  in  the  form  of  an  ointment. 

4.  Resorcin  allays  the  oedema  of  the  turbinated  bodies,  checks  the  over -secretion  of 
the  mucous  glands,  and  leaves  the  membrane  in  a normal  condition. 

5.  In  acute  coryza  resorcin  is  not  necessary  ; in  atrophic  and  in  hypertrophic  rhinitis 
: it  is  not  useful. 

6.  Its  good  effects  are  due  to  its  power  of  lessening  the  caliber  of  the  hypersemic 
•<  vessels,  of  reducing  the  oedematous  and  semi-hypertrophic  mucous  membrane,  and  of 
j hardening  (tanning)  the  epithelial  cells,  and  to  its  remarkable  anti-mycotic  properties. 


DISCUSSION. 

Dr.  J.  A.  Stucky,  of  Lexington,  Ky. , said — I desire  to  make  only  a few 
I remarks  on  the  very  valuable  and  practical  paper  of  Dr.  Thrasher.  Two  years 
i ago,  I mentioned  at  the  Kentucky  State  Medical  Society  my  views  as  to  the  use  of 
I resorcin  in  atrophic  rhinitis.  Since  then  I have  used  the  remedy  in  the  manner  men- 
i tioncd  by  the  speaker,  but  in  much  stronger  solution.  A five  to  twenty  per  cent,  of 
' resorcin,  in  equal  parts  of  glycerine  and  water,  applied  ten  or  fifteen  times,  two  or 
* three  times  a week,  not  only  relieves  the  turgescence  and  tumefaction  of  the  mucous 
membrane  quickly,  but  in  the  large  majority  of  cases  permanently. 

In  hypertrophy  or  hyperplasia,  a saturated  solution  of  resorcin  in  glycerine  and 
water,  with  five  grains  of  cocaine  to  the  drachm,  applied  by  means  of  the  cotton- 
ri  covered  probe,  affords  a quick  and  satisfactory  cure,  if  the  hypertrophy  is  not  too 


58 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


large.  The  rapid  oxygenation  of  the  tissues  caused  by  the  remedy  produces  some 
pain,  but  lasts  only  a moment.  After  the  application  of  resorcin,  I think  the  parts 
should  be  covered  with  spray  of  an  oleaginous,  soothing  substance,  either  vaseline  or 
olive  oil. 


In  the  absence  of  Dr.  F.  Semeleder,  of  Mexico,  Dr.  S.  N.  Benham,  of  Pitts- 
burgh, was  appointed  to  read  his  paper,  entitled — 

TWENTY  YEARS  OF  LARYNGOSCOPICAL  WORK  IN  MEXICO. 

VINGT  ANS  DE  TRAVAUX  LARYNGOSCOPIQUES  AU  MEXIQUE. 

ZWANZIG  JAHRE  LARYNGOSKOPISCHER  THATIGKEIT  IN  MEXICO. 

BY  DR.  F.  SEMELEDER, 

Of  Mexico. 

When,  in  1864,  I came  with  the  Emperor  Maximilian  to  this  country,  laryngoscopy 
was  still  unknown  here,  so  it  took  that  then  new  branch  of  medicine  six  years  to  cross 
the  Atlantic.  The  physicians  of  the  country  had  then  no  scientific  intercourse  with 
any  other  country  but  France.  Whatever  was  done  outside  of  France  no  notice  was 
taken  of  until  it  became  known  through  the  mediation  of  French  books  or  papers.  The 
United  States  was  then,  practically,  far  more  distant  than  France  or  England;  railways 
did  not  exist  here,  nor  direct  steamship  communication.  It  was  a great  deal  easier  to 
get  anything  from  France  than  from  New  Orleans  ; the  English  language  was  hardly 
appreciated  or  cultivated  among  the  profession,  and  German  was  altogether  neglected. 

I had  then  already  published  a monograph  on  rhinoscopy  and  the  first  manual  of 
laryngoscopy,*  both  considered  in  one  volume,  and  translated  into  the  English  language 
by  the  now  deceased  Dr.  Edw.  T.  Caswell,  of  Providence,  E.  I. ; published  by  W.  Wood 
& Co.,  New  York,  1866. 

Since  then  I have  occasionally  practiced  laryngology  and  rhinology,  and  propose,  in 
the  following,  to  give  a brief  account  of  my  work. 

The  only  Mexican  publications  on  the  subject  I am  aware  of,  are:  “La  Laringo- 
scopia,”  etc.,  por  Angel  Iglesias,  printed  in  Paris  by  Rosa  & Bouret,  1868;  and  a 
translation  into  the  Spanish  language  of  my  first  two  cases  of  “ Extirpation  of  Laryn- 
geal Polypi  through  the  Mouth  ;”  f besides  a verbal  communication  to  the  Academy  of 
Medicine  of  “A  Successful  Extirpation  of  a Papilloma  of  the  Vocal  Cords  per  Vias- 
Naturales.” 

Taken  as  a specialty,  laryngoscopy  in  this  country  was  certainly  a most  ungrateful 
business,  and  would  hardly  pay  one’s  house  rent. 

Laryngeal  affections  are  comparatively  rare  here,  owing  to  the  mildness  and  equa- 
bility of  the  climate. 

Acute  and  subacute  laryngitis  are  common  ; the  chronic  form  is  rare.  (Edema  of 
the  larynx  I only  observed  in  one  case,  where  laryngotomy  was  performed  by  a friend 
of  mine,  and  with  good  results. 


* “Dio  Rhinoskopie,”  etc.,  Leipzig,  W.  Engelmann,  1862;  and  “Die  Laryngoskopie,”  Wien, 
Wilh.  Braumiillor,  1863.  f Gaceta  medica  de  Mexico,  V ol.  IV,  No.  6,  1869. 


SECTION  XIII — LARYNGOLOGY.  59 

Tuberculous  laryngitis  I saw  iu  five  cases  ; three  of  them  were  laryngotomized  by 
me,  with  immediate  good  result ; two  of  them  died  later  on  ; one  left  the  city  for  his 
home  and,  probably,  must  have  died.  In  none  of  these  cases  the  pulmonary  affection 
was  much  advanced  at  the  time  wheu  surgical  interference  was  required,  to  prevent 
choking. 

Of  syphilitic  laryngitis,  I have  seen  a number  of  cases  iu  different  stages.  Laryn- 
gotomy  performed  in  eleven  cases,  with  good  results. 

Diphtheria  is  happily  rare  here.  The  Mexicans  pretend  that  it  was  altogether 
unknown  here  until  about  1860  or  1862.  We  had  two  epidemics,  pretty  severe  ; now 
for  several  years  past  we  had  only  single  cases.  I have  performed  laryngo-tracheotomy 
for  croup  iu  two  cases,  both  unfortunate  as  to  the  liual  result. 

Motor  affections  I observed  in  three  cases  of  paralysis  without  appreciable  causes,  if 
not  oedematous  infiltration  of  the  bands  and  the  mucous  membrane  ; in  a fourth  case 
the  paralysis  was  due  to  aneurism  of  the  arteria  auonyma. 

Benignant  tumors ; only  three  cases  belonging  to  Mexicans.  I saw  several  more, 
but  the  patieuts  were  foreigners,  and  all  but  one  only  transient  in  the  city  of  Mexico. 
On  a young  German  I performed  extirpation,  per  vias  naturales,  of  a papilloma  of  the 
left  vocal  cord.  Result  good  ; singing  voice  reestablished. 

Of  people  of  the  country,  I only  know  of  two  cases  of  papillomata  of  the  vocal  bands. 
The  first  I saw  in  1868 ; woman,  thirty-eight  years  old  ; papilloma,  the  size  of  a mul- 
i berry,  left  vocal  band  ; extirpated  per  os.  The  second  case,  a man,  presented  himself 
in  1885 ; twenty-eight  years  old  ; two  papillomata,  the  size  of  a pea  each,  one  in  the 
anterior  angle  and  the  other  on  the  lower  surface  of  the  left  vocal  band,  about  its 
middle ; both  extirpated  per  os,  the  latter  with  some  difficulty.  The  patient  had 
repeatedly,  before  he  came  to  me,  when  he  had  spells  of  coughing,  expectorated  small, 
fleshy  particles  of  the  tumors  and  a few  drops  of  blood. 

I In  one  case,  a lady  of  about  forty  years,  whom  I saw  only  once,  I observed  on  the 
left  vocal  band  a flattish  tumor,  size  of  a cherry  stone,  bluish,  which  I took  for  a varix. 
The  lady  did  not  like  to  have  anything  done  to  her  tumor,  and  left  town  at  once. 

In  two  cases,  one  a young  man,  and  one  a woman  between  thirty-five  and  forty 
years,  I saw  ulcers  and  scars  in  the  pharynx  and  larynx,  which  I took  for  lupus. 

Malignant  tumors,  in  different  stages  and  varieties,  cancer,  epithelioma,  encephaloid 
i and  scirrhus,  epithelioma  being  the  more  frequent  among  my  cases.  The  duration  of 
the  cases  is  extraordinary.  I have  seen  patients  lasting  three  years,  with  two  and  three 

I epochs  of  so  much  improvement  that  I myself  thought  I had  made  a mistake  in  diag- 
nosis. I performed  seven  laryngotomies  for  cancer,  all  with  temporary  good  results. 

All  my  cancer  patients  were  of  advanced  age,  and  all  men  but  two. 

Of  remarkable  rhinoscopical  cases,  I will  only  mention  three  cases  of  retro-pharyngeal 
fibromatous  polypi— one  a young  man,  one  a girl  of  eighteen  years,  and  a woman  of 
forty-two.  For  the  girl,  I extirpated  the  tumor  through  the  nose,  with  good  effect; 
size  like  the  first  phalanx  of  index  finger ; no  reproduction  in  seventeen  years. 


60 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  the  absence  of  Dr.  F.  B.  Eaton,  of  Portland,  Oregon,  Dr.  Richard  H. 
Thomas,  of  Baltimore,  was  appointed  to  read  his  paper,  entitled — 

THE  PRESENT  STATUS  OF  THE  GALVANO-CAUTERY  IN  THE 
TREATMENT  OF  DISEASES  OF  THE  UPPER  AIR  PAS- 
SAGES. ILLUSTRATED  BY  IMPROVED  FORMS  OF 
ELECTRODES  AND  A DESCRIPTION 
OF  CASES. 

LA  CONDITION  PRESENTE  DU  GALVANO-CAUTERE  DANS  LE  TRAITEMENT  DES 
MALADIES  DES  VOIS  RESPIRATOIRES  SUPERIEURES,  ILLUSTREE 
PAR  DES  ESPECES  D’ELECTRODES  PERFECTIONES,  ET 
UNE  DESCRIPTION  DE  CAS. 

DERGEGENWARTIGE  STAND  DER  GALVANO-KAUSTIK  IN  DER  BEHANDLUNG  DER  KRANK- 
HElTEN  DER  OBEREN  LUFTWEGE,  ERLAUTERT  DURCH  ELEKTRODEN 
VERBESSERTER  FORM,  UND  BESCHREIBUNG  VON 
FALLEN. 

BY  FRANK  B.  EATON,  M.D., 

Of  Portland,  Oregon. 

The  surgical  is  now  the  most  popular  if  not  the  prevailing  method  of  treatment  in 
chronic  diseases  of  the  upper  air  passages.  This  is  due,  in  a great  measure,  to  the  oppor- 
tunity offered  by  cocaine,  and  also  to  the  brilliant  results  obtained  in  many  cases.  At  all 
events,  the  inventive  faculty  ofTnany  surgeons  is  now  stimulated  to  such  an  extent  in 
the  field  of  nasal  surgery,  that  if  all  the  assertions  made  in  our  journals  are  to  be  relied 
upon,  the  air  passages  can  be  cleared  in  one  sitting  with  little  or  no  prfin. 

There  is,  nevertheless,  a want  of  unanimity  among  specialists  as  to  what  is  the  best 
general  plan  of  removing  hypertrophic  tissue  in  the  anterior  and  posterior  nares,  and 
evidence  of  such  difference  of  opinion  is  not  wanting  in  the  reports  of  medical  acade- 
mies and  societies,  each  writer  appearing  to  narrow  himself  as  much  as  possible  to  his 
own  method  instead  of  utilizing  the  good  features  of  all.  As  far  as  can  be  gathered 
from  such  reports  and  from  the  various  articles  published  during  the  last  two  or  three 
years,  the  prevailing  tendency  is  to  adopt  more  and  more  radical  methods,  so  that  now 
we  have  progressed  ou  from  the  mild  treatment  by  bougies  to  the  use  of  snares,  the  gal- 
vano-cautery,  and,  finally,  to  that  by  revolving  drills  actuated  by  an  electric  motor. 

Owing  to  the  extreme  prevalence  of  chronic  nasal  catarrh  in  America,  the  popular- 
ity of  all  these  methods  is  assured.  That  they  have  been,  and  will,  one  and  all,  be 
abused  and  overdone,  and  that  a reaction  must  necessarily  follow  excessive  zeal  in 
clearing  the  upper  air  passages,  goes  without  saying.  Indeed,  something  of  a reaction 
against  indiscriminate  surgical  interference  with  these  parts  has  already  set  in;  a sort 
of  therapeutic  skepticism,  if  I may  employ  the  term,  as  to  the  value  of  topical  medi- 
cation of  the  nasal  and  post-nasal  mucous  membrane,  being  one  of  the  resultant  evils 
against  which  Dr.  J.  M.  W.  Kitchen,  of  New  York,  has  protested  in  an  exceedingly 
fair,  able  and  temperate  communication  (Medical  Record,  May  14th,  1887).  Nor  can  it 
be  denied  that  this  excessive  trust  in  surgical  methods  has  called  away  due  attention 
from  hygienic  prophylaxis  and  treatment,  which  are  of  such  paramount  importance  in 
nasal  diseases.  Specialism  in  our  art  should  be  viewed  more  as  an  unfortunate  but 
unavoidable  necessity,  resulting  from  the  fact  that 

“Art  is  long  and  time  is  fleeting,” 

than  as  a mercenary  choice,  and  the  aim  of  the  specialist  should  not  be,  as  it  seems  to  l>e, 
to  effect  complicated  apparatus  and  to  arrogate  it  to  himself,  but  to  simplify  and  to 


SECTION  XIII — LARYNGOLOGY. 


61 


make  known  to  the  profession  at  large  his  operative  methods  as  much  as  possible,  that 
'.they  may  be  rendered  available  to  the  general  practitioner,  and  thus  the  field  of  use- 
fulness enlarged. 

The  principal  aim  of  this  paper  is  to  claim  again  for  the  galvauo-cautery  (see  Medi- 
\ cal  Record,  August  28th,  1886)  that  in  the  form  I here  present  it  to  you,  it  is  one  of  the 
best  and  most  available  surgical  instruments  for  the  removal  of  nasal  and  post-nasal  obslruc- 
> Horn  now  at  the  disposal  of  the  majority  of  surgeons  at  present  practicing  in  our  cities.  I 
■ hasten,  however,  to  state  emphatically  that  I do  not  claim  for  the  cautery  an  exclusive 
i value  in  comparison  with  other  operative  methods,  some  of  which  are  clearly  more  radi- 
t cal  for  the  removal  of  certain  obstructions,  though  more  complicated,  severe,  and  less 
! easily  managed;  and  I shall  honestly  enumerate,  with  its  advantages,  its  objectionable 
features. 

I submit  this  testimony  to  the  value  of  the  galvano-cautery  in  nasal  diseases  partly 

* as  a vindication,  in  answer  to  what  I must  designate  as  an  unjust  attack  upon  it  by 
those  who  seem  to  favor  the  exclusive  use  of  chromic  acid,  saws,  snares,  etc.  And  I 

[ am  prepared  to  take  issue  with  and  prove  the  unfairness  of  one  well-known  specialist, 
i who,  not  long  ago,  made  the  sweeping  assertion  that  “ a crystal  of  chromic  acid  accom- 
plishes all  that  the  platinum  wire  can  possibly  accomplish,  ...  it  can  be  applied  with 
1 far  more  accuracy,  its  action  controlled  with  far  more  delicacy,  and  it  also  creates  a 
more  efficient  slough.  While  the  galvano-cautery,  on  the  other  hand,  is  a cumbersome, 
j expensive,  disappointing,  troublesome  device,  and,  also,  is  not  unattended  with  danger.” 
[F.  H.  Bosworth,  M.D.,  New  York  Academy  of  Medicine,  April  21st,  1887.] 

Now,  I believe  that  such  unqualified  assertions  and  such  fulsome  laudations  of  a 
particular  method  of  treatment  are  precisely  what  injure  it  in  particular  and  surgery 
f in  general,  and  while  endeavoring  in  this  paper  to  present  fairly  the  true  value  of  the 

* galvano-cautery,  and  the  improvements  I and  others  have  introduced  in  the  apparatus, 

II  repeat  again  that  I do  not  wish  to  convey  the  idea  that  it  is  facile  princeps,  but,  that 
in  respect  to  general  availability  to  the  operator  of  average  skill  and  adaptability  to  the 
greatest  variety  of  conditions,  it  is,  in  my  opinion,  preeminent. 

Let  me  consider  some  of  the  above-quoted  objections  to  the  galvano-cautery: — 

1.  That  it  is  cumbersome.  Compared  with  the  chromic  acid  crystal,  no  doubt  it  is, 
but  only  relatively.  The  battery  I here  show  you  is  that  devised  by  Dr.  Seiler;  it 
J occupies  a space  only  18  by  13  by  11  inches,  permitting  it,  as  in  my  office,  to  be  placed, 
when  being  used,  out  of  the  way,  under  a bracketed  operating  table  ; it  is  indeed  for 
from  cumbersome. 

2.  That  it  is  expensive.  This  objection  is  also  a relative  one,  battery  and  electrodes 
I costing  only  $70.00;  certainly  no  great  expense  in  view  of  the  fact  that  both  are  lasting 
and  durable,  for  the  first  expense  is  practically  the  only  one. 

3.  That  it  is  disappointing.  I can  aver  that,  on  the  contrary,  it  has,  in  the  form  used 
by  me,  surpassed  all  my  expectations,  which  were  very  sanguine.  I can  best  refute  the 
i objection  that  the  cautery  is  disappointing,  by  giving  the  results  of  treatment,  as  I will 
I further  on. 

Finally,  to  the  assertion  that  the  galvano-cautery  is  a troublesome  device,  I repeat 
i that  in  its  most  recent  improved  forms  it  is  far  less  so  than  chromic  acid,  if  I can  judge 
by  the  complaints  made  to  me,  and  the  published  experiences  of  other  surgeons. 

It  is  difficult  to  understand  how  the  action  of  chromic  acid,  as  has  been  asserted, 

! “ can  be  controlled  with  far  more  delicacy  than  the  platinum  wire.”  This  may  be 
true  in  respect  to  some  forms  of  batteries  and  electrodes,  but  the  characteristic  and 
most  valuable  features  of  the  apparatus  I present  to  you,  are  the  perfect  control  which 
the  operator  has  over  the  current  in  respect  to  its  quantity  and  duration,  the  delicacy 
of  the  electrodes  and  their  adaptability  to  different  conditions.  It  is  useful  to  view  the 
electrodes  contrasted  with  the  application  of  chromic  acid,  as  probes  variously  bent,  by 


62 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


means  of  which  caustic  heat  is  so  supplied  as  to  cauterize  or  destroy  only  the  part 
touched  hy  the  incandescent  platinum,  and  in  proportion  to  its  size,  temperature  and 
the  extent  to  which  this  platinum  is  pressed  into  the  tissue  by  the  hand  of  the  opera- 
tor, is  the  effect  produced.  Will  it  be  claimed  that  chromic  acid  can  be  thus  con- 
trolled ? I think  not. 

As  to  the  positive  advantages  of  the  galvano-cautery,  they  are  not  to  be  despised. 

1.  There  is  nothing  in  the  appearance  of  the  apparatus  to  alarm  timid  patients,  so 
many  of  whom  are  intimidated  by  the  snare,  saws,  knives  and  drills,  so  as  to  abso- 
lutely refuse,  in  some  cases,  to  submit  to  an  operation.  The  very  brief  duration  of  the 
application  of  the  incandescent  burner  is  another  admirable  feature.  I have  applied 
my  “scythe  ” burner  to  a posterior  inferior  hypertrophy,  immediately  following  it  up 
with  a “lateral  ” burner  and  destroying  all  the  remains  of  hypertrophied  tissue  on  the 
same  inferior  turbinated  bone  within  the  short  space  of  a minute,  and  that  without 
giving  any  pain,  or  causing  the  slightest  hemorrhage.  Pain  continuing  during  its 
necessarily  protracted  application  to  a posterior  hypertrophy  is  inseparable  from  the 
use  of  the  snare,  with  or  without  cocaine,  in  order  to  prevent  hemorrhage;  whereas, 
when  a 20  per  cent,  solution  of  cocaine  is  used  there  is  none  caused  by  the  cautery,  except 
sometimes  when  deeply  burning,  and  then  it  is  never  severe.  Hemorrhage  beyond 
slight  and  brief  oozing  is  rare  in  my  experience.  Cautery  operations,  with  proper  tem- 
perature of  platinum,  are  essentially  dean  ones. 

Again,  all  forms  of  hypertrophic  obstruction  of  the  upper  air  passages  can  be 
removed  by  means  of  the  cautery,  save  large  exostoses. 

Every  operative  method  has  limitations  and  objectionable  features  ; so  with  the 
galvano-cautery.  While  thin,  shelf-like  exostoses  of  the  septum  can  readily  be  cut 
through  and  destroyed  by  a spatula  burner  kept  at  a high  temperature,  of  course  the 
larger  ones  cannot,  and  require  the  use  of  a drill  or  saw. 

Large  enchondromas  I find  can  in  most  cases  be  readily  destroyed  either  by  cutting 
them  off  with  a knife-like  burner,  or  causing  their  absorption  by  puncturing  them  with 
a pointed  burner.  On  several  occasions,  however,  I found  such  puuctures  only  stimu- 
lated the  larger  growths,  and  even  caused  the  peculiar  cystic  or  fatty  degeneration  to 
which  they  are  liable,  and  a general  increase  of  the  tumor.  Naturally,  large  hyper- 
trophied pharyngeal  tonsils  can  best  be  removed  by  cutting  forceps,  such  as  Loewen- 
berg’s;  and  although  in  one  case  I operated  by  way  of  the  mouth  upon  the  enlarged 
pharyngeal  tonsil  of  a child  of  twelve  years  successfully  with  my  “S”  burner,  I 
believe  the  operation  par  excellence  for  this  form  of  hypertrophy  in  children  is  to 
scrape  it  out  with  the  finger  nail.  In  adults  this  tonsil,  when  sessile,  can  best  be 
Temoved  by  the  cautery. 

In  what  way  is  the  beneficial  effect  of  the  cautery  accomplished  ? It  was  at  one 
time  the  practice  of  certain  operators  to  produce  only  a very  superficial  slough,  and 
lately  it  h;is  been  claimed  that  “ the  object  to  be  accomplished  by  the  use  of  the  cautery 
is  not  the  destruction  of  tissue.  . . . A caustic  applied  on  the  superficial  layer  of  the 

mucous  membrane  reduces  the  amount  of  blood  supply  to  the  part,  arrests  hypersemia, 
diminishes  nutrition,  and  in  this  way  restores  healthy  action.”  [F.  H.  Bosworth, 
Ibid.]  While  this  may  be  sound  reasoning,  as  regards  the  proper  local  therapeutics 
of  simple  chronic  rhinitis,  it  needs  qualifying  as  regards  chronic  hypertrophic  rhinitis  in 
which  the  nares  have  become  the  seat  of  permanently  hypertrophied  mucous  tissue. 
Thus  Schaeffer  (“  Chirurgisclie  Erfahrungen  in  der  Rhinologie  und  Laryngologie ,”  pages 
16  and  171,  in  describing  the  treatment  of  chronic  hyperplastic  rhinitis,  says,  “ I have 
used  chromic  acid  in  mild  cases  always  with  the  object  of  removing  chronic  hyperplastic 
rhinitis.  . . . In  describing  my  operative  method  (by  galvano-cautery)  I may  state  at 
the  outset  that  I,  as  well  as  Bresgen,  from  the  first  aimed  at  making  a furrow;  I antici- 
pating that  the  resulting  cicatrix  should  become  bound  down  to  the  concha  by  the 


SECTION  XIII — LARYNGOLOGY. 


G3 


inflammation  produced  and  bring  about  free  ventilation  of  the  nose.  . . . Hack 
laid  the  most  weight  on  his  so-called  puncturing  method  ( Stichel  Methode),  but  later 
, adopted  the  same  view  as  the  rest  of  us,  that  above  all  things  a radical  destruction  of 
the  hyperplasias  is  necessary  to  accomplish  a permanent  result.” 

The  plan  introduced  by  Dr.  Schweig,  of  making  one  puncture  in  anterior  hyper- 
trophies (Medical  Record,  Yol.  29,  p.  206)  with  a galvano-cautery  point,  thus  permanently 
collapsing  them  while  preserving  the  overlying  mucous  membrane  with  its  glands,  is 
the  only  modification  of  the  above  quoted  views  that  I believe  advisable  in  the  treat- 
ment of  turbinated  hypertrophies,  so  called,  although  it  is  only  useful  where  there  is 
merely  erection  of  the  turbinated  body,  and  not  in  true  hypertrophy. 

I described  in  detail  the  burners  I now  show  you  in  the  Medical  Record  of  Aug.  28th, 
1886,  so  I will  now  only  briefly  refer  to  their  forms  and  uses.  All  the  burners  are  com- 
plete in  themselves,  being  only  attached  directly  to  conducting  cords  from  Dr.  Carl 
; Seiler’s  cautery  battery,  and  the  circuit  is  closed  with  the  foot,  thus  raising  the  cups. 

The  heavy  handle,  so  long  in  vogue,  is  therefore  not  used,  and  delicacy  of  touch  and 
I ease  and  correctness  of  manipulation  are  secured. 

The  most  generally  useful  are  the  “ scythe  ” and  “ lateral  ” burners  (No.  4,  A and 
B,  and  No.  3,  A and  B),  which  have  the  same  length  and  are  bent  at  the  same  angle  as 
the  long  spatula  burner  (No.  1,  A).  The  scythe  burner  is  most  useful  for  the  destruction 
of  posterior  hypertrophies  of  the  middle  and  inferior  turbinated  bones.  I have  also 
used  them  to  destroy  the  wing-like  hypertrophies  so  often  seen  on  each  side  of  the 
: posterior  extremity  of  the  vomer.  The  lateral  burners  are  used  mainly  for  the  destruc- 
c tion  of  the  hypertrophied  or  erected  tissue  along  the  length  of  the  middle  and  inferior 
turbinated  bones,  the  lateral  position  of  the  platinum  wire  permitting  it  to  be  passed 
along  a very  narrow  nostril  and  rendering  a protecting  plate  unnecessary.  The  long 
and  short  spatula  burners  I employ  mainly  to  cut  off  shelf-like  enchondroses  and  exos- 
toses of  the  septum,  using  them  as  knives.  Although  simply  sinking  them  deeply  here 
and  there  in  these  tumors  is  sufficient  often  to  bring  about  their  speedy  absorption,  I 
tried  in  one  case  of  enchondrosis  Dr.  Jarvis’s  plan  of  freezing  the  enchondroma  with 
a rhigolene  spray,  and  used  a sharp  spatula  with  which  to  shave  off  the  growth,  but 
the  resulting  bleeding,  though  not  very  profuse,  was  not  easily  checked,  and  I have 
since  preferred  the  burner. 

For  exostoses  too  bulky  to  be  burned  off  I have  employed  Dr.  Bosworth’s  saws. 
The  pointed  burner , No.  6,  I have  reserved  entirely  for  cases  of  persistent  erection  of  the 
» anterior  portions  of  the  inferior  turbinated  body,  puncturing  them  and  freely  removing 
the  glowing  point  about  beneath  the  mucous  membrane.  It  is  useless  in  true  anterior 
I hypertrophy. 

The  post-nasal  scythe  burners  (No.  5,  A and  No.  5,  B),  designed  by  Schalle  for  the 
■ destruction  of  adenoid  vegetations  and  the  pharyngeal  tonsil  in  the  post-nasal  space  in 
children,  I rarely  use,  believing  the  finger  nail  to  be  the  best  instrument  for  the  pur- 
< pose. 

For  sessile  hypertrophies  of  the  pharyngeal  tonsil  in  adults,  I use  the  “5”  burner 
• (No.  2,  Bj,  with  which,  by  bending  it  appropriately,  I can  reach  all  parts  of  the  pharyn- 
i geal  roof. 

In  operating  I use  a 20  per  cent,  solution  of  cocaine,  by  means  of  a cotton  carrier,  or 
by  spray,  and  pain  is  rarely  complained  of.  By  properly  controlling  the  burner,  keep- 
; ing  it  always  aglow  and  always  moving,  hemorrhage,  save  a little  oozing,  is  rare. 

I have  kept  a sufficiently  exact  record  from  which  to  draw  conclusions  in  the  last 
! forty  cases  of  nasal  and  post-nasal  obstructions  treated  by  me  in  private  practice  with 
my  burners,  and  will  present  a brief  analysis  of  them. 

While  the  number  of  cases  is  comparatively  limited,  my  record  of  them  is  so  com- 
plete in  all  the  details  of  history,  objective  symptoms,  operations  and  results,  that  I feel 


64 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


DK.  F.  B.  EATON’S  NASO-PHARYNGEAL  CAUTERY  ELECTRODES. 

1,  A.  Long  Spatula  Burner,  for  hypertrophy  of  turbinated  hones. 

1,  B.  Short  Spatula  Burner,  lor  anterior  hypertrophy  of  turbinated  bones. 

2,  A.  Lateral  “8”  Burner,  for  growths  on  post-nasal  walls. 

2,  B.  “ S”  Burner,  for  growths  on  post-nasal  roof. 

B,  A.  Lateral  Burner,  for  right  nostril,  for  hypertrophy  of  turbinated  bones. 

3,  B.  The  same,  for  left  nostril. 

4,  A.  Scythe  Burner,  for  right  nostril,  for  posterior  hypertrophies  of  turbinated  bones. 

4,  B.  The  same,  for  left  nostril. 

5,  A.  Post-nasal  Scythe  Burner,  for  growths,  in  post-nasal  space. 

5,  B.  The  same,  of  smaller  size  for  children. 

6,  Pointed  Burner,  for  puncturing  anterior  hypertrophies. 


SECTION  XIII — LARYNGOLOGY. 


6 5 


justified  in  offering  this  analysis  as  a contribution  to  our  knowledge  of  the  value  of 
i the  cautery  in  rhinology.  The  cases  are  not  selected,  being  the  last  forty  consecutive 
i cases  recorded  in  my  case-book  up  to  July  1st,  1887. 

Number  of  cases,  40.  Male,  30.  Female,  10. 

Subjective  Symptoms. — Loss  of  night  rest  from  obstructed  breathing,  2.  Snoring,  7. 
Habitual  mouth  breathing,  10.  Deafness,  20.  Tinnitus  aurium,  18.  Asthma,  2. 
Headache,  3.  Dropping  of  mucus  from  above  palate,  17.  Pharyngitis,  6.  Epiphora, 
2.  Epistaxis,  3 cases.  Obstructed  nasal  respiration  (often  not  complained  of,  although 
existing),  23.  Anosmia,  1. 

Objective  Symptoms. — Polypi,  4;  3 R,  1 L.  Hypertrophy  of  middle  turbinated 
body,  12;  11  R,  9 L.  Persistent  erection  of  inferior  turbinated  body,  13;  13  R,  13  L. 
Hypertrophy  of  inferior  turbinated  body,  25;  20  R,  24  L.  Posterior  inferior  hyper- 
trophy, 13;  13  R,  13  L.  Enchondrosis  of  septum,  19;  9 R,  15  L.  Simple  chronic  post- 
i nasal  catarrh,  6.  Chronic  hypertrophic  post-nasal  catarrh,  23.  Hypertrophy  of  pharyn- 
geal tonsil,  6.  Deflection  of  septum  (marked),  9;  1 to  R,  8 to  L.  Exostosis  of  septum, 
5.  Pharyngitis,  11.  Atrophic  nasal  catarrh,  1.  Changes  in  membrana  tympani 
(marked),  27. 

Operations. — Middle  turbinated  bodies,  9 operations  on  4 patients;  R 5,  L 4.  Pos- 
terior inferior  hypertrophies,  21  operations  on  13  patients;  10  R,  11  L.  Anterior  and 
middle  portions  of  inferior  turbinated  bodies,  51  operations  on  32  patients;  25  R,  26  L. 
Posterior  middle  hypertrophies,  7 operations  on  4 patients;  3 R,  4 L.  Hypertrophies 
of  posterior  extremity  of  vomer,  5 operations  on  4 patients;  3 R,  2 L. 

Enchondroses,  32  operations  on  22  patients;  9 R,  2 3 L.  Exostoses  of  small  vomer, 
9 operations  on  4 patients,  all  on  left  side.  Pharyngeal  tonsil,  13  operations  on  4 
patients.  Polypi,  3 operations  on  two  patients;  2 R,  2 L.  Punctured  anterior  inferior 
hypertrophies  about  six  times  on  5 patients. 

RESULTS. 

(1)  Cured  (excluding  aural  symptoms)  

(2)  Relatively  cured,  i.  e.,  of  all  subjective  symptoms  (ex- 
cluding ear.)  15  = 37.5  per  cent. 

(3)  Subjective  and  objective  symptoms  greatly  improved 

(including  ear.)* 

(4)  Subjective  and  objective  symptoms  slightly  improved 

(including  ear) 

(5)  Lost  sight  of 

As  regards  the  very  small  number  of  cures  recorded,  I may  state  that  I consider  no 
case  cured  unless  all  the  subjective  and  objective  symptoms  are  removed,  a result 
which,  as  is  well  known,  is  almost  impossible  in  chronic  nasal  and  post-nasal  catarrh. 
The  principal  subjective  symptoms  entirely  relieved  and  recorded  above  as  relatively 
cured  (37.5  per  cent.)  were  obstructed  nasal  respiration , and  excessive  discharge. 

REMARKS. 

It  is  not  within  the  scope  of  this  paper  to  present  the  complete  record  of  my  cases. 
I may,  however,  mention  a few  points  of  treatment,  which,  as  far  as  I know,  have  not 
yet  been  referred  to  as  regards  the  cautery. 

Of  late,  in  several  cases,  I have  with  my  spatula  burners  at  a white  heat  cut  through 
medium-sized  shelf-like  exostoses  of  the  septum  of  considerable  length.  In  one  case, 
where  the  left  naris  was  so  occluded  that  the  patient  could  barely,  with  considerable 
effort,  force  air  through  it,  I found  the  septum  moderately  deflected  to  the  left,  and  a 


* (3)  necessarily  includes  (2). 


2 5 per  cent. 

30  75  percent. 

6 15  “ 

2 5 “ 

40  100  per  cent. 


66 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


large  shelf-like  tumor  extending  half  way  back  and  touching  the  opposite  inferior  tur- 
binated body.  With  my  spatula  burners  I cut  off,  at  one  sitting,  the  whole  growth 
close  to  the  septum,  and  found,  on  examining  the  piece,  that  instead  of  being  cartila- 
ginous, it  was  mainly  composed  of  bone  covered  with  cartilage.  For  large  exostoses,  I 
use  Dr.  Bosworth’s  saws,  which  I find  accomplish  the  end  very  successfully.  In  a few 
cases  of  polypus,  too,  where  I have  found  it  difficult  or  impossible  to  apply  the  snare,  I 
have  succeeded  easily  in  removing  them  with  the  scythe  burner,  by  passing  this  behind 
the  pedicle  and  cutting  it  olf. 

As  to  topical  applications,  I nearly  always  follow  up  the  removal  of  obstructing 
hyperplasias  with  Dr.  Leffert’s  solution  iu  the  form  of  a spray,  and  sometimes,  in  marked 
general  hypertrophic  thickening  of  the  mucous  membrane  of  the  post-nasal  space,  I 
apply  silver  nitrate,  two  drachms  to  the  ounce,  to  the  entire  surface. 

I have  had  no  experience  with  the  galvano-cautery  snare,  nor  have  I any  intention 
of  employing  it  since  reading  the  following  passage  in  Hack’s  famous  brochure  concern- 
ing his  experiences  with  it  for  the  removal  of  turbinated  hypertrophies:  “.  . . In 

spite  of  all  foresight,  I uniformly  met  with  profuse  hemorrhage  from  the  opened  caver- 
nous spaces,  which  could  with  difficulty  be  checked  even  by  exact  tamponading,  an 
accident  which  entails  quite  a loss  of  time.”  (Dr.  Wilhelm  Hack,  “Ueber  tine  operative 
Radical- Behandlung  bestimmter  Formen  von  Migrdne,  Asthma,  Heufieber,  etc.,'1'1  1884.) 

In  conclusion,  I submit  the  following  propositions 

1.  The  galvano-cautery  in  its  improved  forms  is  the  most  generally  useful  and 
available  means  now  at  the  disposal  of  the  majority  of  practitioners  for  the  surgical 
treatment  of  diseases  of  the  upper-air  passages. 

2.  For  the  treatment  of  turbinated  hypertrophies  the  cautery  possesses  the  advan- 
tage over  the  cold  snare  of  causing  little  or  no  pain,  of  being  more  easily  and  quickly 
applied,  and  of  being  less  intimidating  to  the  patient.  In  the  same  class  of  cases  the 
cautery  has  the  advantage  over  chromic  acid  of  being  safer,  more  easily  controlled,  more 
effective  and  of  being  adapted  to  a greater  variety  of  conditions. 

3.  While  small  exostoses  and  medium-sized  enchondroses  of  the  septum  may  be 
removed  by  the  cautery,  the  larger  growths  are  not  suitable  for  such  treatment. 

4.  For  the  removal  of  the  large  and  projecting  pharyngeal  tonsil  in  adults,  other 
means  are  to  be  preferred  to  the  cautery,  and  the  latter  is  relatively  less  suitable  for  the 
removal  of  such  growths  occurring  in  children.  For  the  sessile  growths  in  adults  the 
cautery  is  to  be  preferred. 

5.  The  above  described  burners  iu  general  possess  great  advantage  in  dispensing  with 
the  use  of  the  heavy  handle,  thus  insuring  delicacy  and  exact  manipulation;  and  in 
particular,  their  varied  forms  permit  every  part  of  the  anterior  and  posterior  nares  to  be 
reached. 

6.  Topical  applications  should,  iu  the  majority  of  cases,  supplement  or  follow  the 
treatment  of  nasal  diseases  by  the  cautery. 


DISCUSSION. 

Dr.  Bermann,  of  Washington,  D.  C. , agrees  with  the  writer  on  the  use  of  the 
galvano-cautery,  but  wishes  to  state  that  the  application  of  chromic  acid  has  proven 
in  a number  of  cases  very  useful.  The  following  method  he  has  seen  used  very  j 
successfully,  first  by  Dr.  Moritz  Schmidt,  of  Frankfort-on-the-Main,  by  which  an 
excessive  application  of  the  acid  is  prevented.  A small  number  of  crystals  of  chromic  i 
acid  are  spread  on  a thin  layer  of  cotton,  about  one  by  two  inches,  and  then  this  cotton 
is  carefully  and  firmly  wrapped  around  a thin  silver  probe.  By  pressing  this  probe 
firmly  against  the  place  to  be  cauterized  we  get  the  full  effect  of  the  acid.  Has  seen 
it  applied  himself  in  this  way  after  drawing  a line  with  the  galvano-cautery  knife 


SECTION  XIII — LARYNGOLOGY. 


67 


through  the  hypertrophied  membrane  of  the  lower  turbinated  bone,  and  then  used 
the  probe  containing  the  acid  on  the  same  place.  It  is  always  to  be  neutralized  with 
bicarbonate  of  soda  in  solution. 

Dr.  Richard  H.  Thomas,  of  Baltimore,  said  he  could  strongly  endorse  what 
Dr.  Eaton  had  said  in  regard  to  the  general  applicability  of  the  galvano-cautery  to 
hypertrophies,  etc.  In  regard  to  new  growths  and  large  posterior  hypertrophies  he 
preferred  the  cold  snare.  He  doubted  the  advisability  of  dispensing  with  the  use  of 
the  handle  and  regulating  the  current  with  the  foot.  He  had  found  that  the  motion 
of  the  foot  in  depressing  the  lever  in  order  to  raise  the  fluid  caused  sufficient  unsteadi- 
ness of  the  operating  hand  to  interfere  with  the  absolute  accuracy  of  the  operation. 
He  also  deprecated  the  indiscriminate  use  of  such  strong  solutions  of  cocaine  as  twenty 
per  cent.  He  had  seen  solutions  of  much  less  strength,  applied  to  the  intra-nasal 
passages,  produce  very  unpleasant,  and  in  one  case  alarming,  symptoms.  A five  per 
cent,  solution  is  often  sufficient  to  produce  the  necessary  anaesthesia. 

Dr.  Ephraim  Cutter,  of  New  York,  said — I am  called  up  by  the  President’s 
kind  reference  to  me.  I wish  to  say  that  I have  a battery  which  I have  used, 
a galvano-cautery  battery,  for  ten  years  at  least.  It  cost  about  ten  dollars.  It  is 
made  of  carbon  and  zinc  plates,  each  one  inch  by  ten  inches;  carbons,  half  inch  thick; 
zincs,  one-eighth  inch  thick,  connected  by  couplings  of  my  invention.  They  go  into 
a single  cell  made  of  paraffine,  black  walnut  covered  with  sheet  lead  on  the  outside. 
This  requires  the  ordinary  bichromate  of  sodium — acid  solution ; one  pint  of  this 
solution  is  enough  to  run  the  battery  fifteen  minutes  for  galvano-caustic  use.  A 
new  solution  is  to  be  used  each  time,  to  be  sure  of  results.  I tested  this  battery 
lately,  when  the  zincs  were  almost  worn  out  by  use,  yet  it  registered  the  same  as  my 
largest  battery  of  thirteen  square  feet  of  surface.  I think  the  Main  Storage  batteiy 
is  the  coming  storage  battery,  though  it  weighs  about  as  much  as  the  Mailer  battery 
I have  referred  to. 


In  the  absence  of  Professor  F.  Massei,  of  Naples,  Italy,  his  paper  was  read,  by 
request  of  the  President,  by  Dr.  Max  Toeplitz,  of  New  York. 

ON  PRIMARY  ERYSIPELAS  OF  THE  LARYNX. 

SUR  L’ERYSIPELE  PRIMAIRE  DU  LARYNX. 

UBER  DAS  PRIMARE  ERYSIPEL  DES  LARYNX. 

A CLINICAL  NOTE  BY  F.  MASSEI, 

Naples,  Italy. 

Erysipelas  of  the  larynx  is  a morbid  process  of  which  we  find  notice  in  several 
authors,  and  even  the  primary  one  has  been  admitted,  although  considered  as  very  rare. 

Old  and  modern  writers  have  hinted  at  its  possibility,  among  whom  me  may  refer 
to  the  names  of  Boyle  (1816),  Porter  and  Ryland  (1837),  Sestier  (1852),  Lendel  (1859). 
But  it  appears  that  Semeleder  and  Turk  were  the  first  who  observed  erysipelas  of  the 
larynx  on  living  subjects. 


68 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


This  notwithstanding,  we  can  confirm  that  in  the  present  laryngoscopical  period  it 
has  been  less  noted  than  in  the  pre-laryngoscopic  time  ; and  if  we  find  in  Ziemssen  and 
Mackenzie’s  hooks  more  exact  details,  it  is  not  without  wonder  that  we  find  in  Ryland 
(1837)  a very  exact  description.  Among  the  moderns,  I quote  the  names  of  Cuire 
(1864),  Radcliffe  (1865),  Campenon  (1872),  Bryson,  Delavan,  Semon  (1885),  Charazac. 
Str'umpel,  etc.,  who  relate  cases  of  the  kind,  and  all  admit  an  erysipelas  of  the  larynx. 
If  we  make,  however,  a minute  analysis  of  all  the  reported  cases,  we  find  either  a 
simple  affirmation,  or  the  confirmation  of  the  erysipelas  of  the  larynx  in  a post-mortem 
examination. 

The  clinical  and  laryngoscopical  characters  for  recognizing,  on  living  subjects,  the 
primary  erysipelas  of  the  larynx,  are  not  described  in  any  of  these  pamphlets  or  books, 
and  iu  those  who  are  acquainted  with  the  laryngoscope  the  opinion  prevails  that  it  is 
an  excessively  rare  disease.  He  who  has  the  more  insisted  is  Ryland,*  but  from  the 
seven  quoted  observations,  it  is  to  be  deduced  : — 

1.  That  for  the  greater  part  the  erysipelas  was  secondary  to  a similar  affection  on  the 
surface  of  the  body  (Cases  I,  II  and  in)  and  appeared  in  patients  affected  with  violent 
lesions. 

2.  That  it  developed  in  hospitals  and  in  patients  who  lived  near  other  patients 
affected  by  erysipelas  on  the  surface  of  the  body,  or  in  hospitals  where  erysipelas  was 
dominant  (Case  iv).  The  erysipelas  was  seen,  not  only  in  the  larynx,  but  also,  in  the 
meantime,  over  the  tonsils  and  pharynx. 

3.  That  once  (Case  vil)  the  erysipelas  began  from  the  tonsils  and  appeared  after- 
ward on  the  skin. 

4.  In  a case  (vi)  in  which  recovery  took  place,  and  in  which  there  was  erysipelas  of 
the  skin,  it  was  highly  questionable  if  it  had  been  present  as  a laryngeal  erysipelas. 

In  the  year  1885  I called  attention  of  the  profession  to  an  affection  of  the  larynx, 
which  has  all  the  clinical  features  of  erysipelas  ; which  appears  primarily,  i.  e.,  without 
appearance  of  erysipelas  of  the  face,  of  the  throat,  or  of  the  body,  in  private  houses, 
and  which  is  not  rare  to  be  seen. 

A diligent  study  of  the  relative  symptoms  has  convinced  me  that  many  of  those  mor- 
bid forms  I described  as  phlegmonous  laryngitis  (primary  oedema  of  the  larynx)  were  to 
be  considered,  vice  versa , as  erysipelas  of  the  larynx,  and  that  in  a general  manner  we 
can  admit  two  forms  ; the  one  in  which  the  local  symptoms  and  fever  prevail,  the 
other  in  which  collapse  is  prevalent.  The  process  can  also,  iu  a later  period,  extend  to 
the  lungs  or  reach  the  fauces  without  the  least  appearance  of  erysipelas  on  the  outer 
surface  of  the  body. 

I have  not  described  in  this  way  a new  disease,  but  I have  well  considered  some 
symptoms,  diligently  followed  with  the  thermometer  and  the  laryngoscope  the  course 
of  the  disease,  and  so  I have  recorded  many  observations  of  the  primary  erysipelas  of 
the  larynx,  subtracting  them  from  the  chapter  of  phlegmonous  laryngitis,  in  which  they 
were  placed  by  mistake.  / 

At  present  they  are  only  clinical  arguments  which  support  my  views  ; in  order  to 
prove  that  I am  right,  it  would  have  been  necessary  to  establish  the  bacteriological 
experiments  ; to  recognize  the  streptococcus  of  Felilisen,  to  cultivate  and  inoculate  it ; 
but  I must  freely  declare  that,  on  a living  person,  in  which  the  symptoms  of  a narrow- 
ing of  the  larynx  are  present,  it  is  not  easy  to  obtain  the  products  in  which  these 
inquiries  are  to  be  made.  Besides  this,  I have,  happily,  to  record  many  recoveries ; 
and  autopsy  was  never  permitted  me,  iu  the  cases  which  ended  fatally,  as  they  belonged 
to  private  families.  Nobody  has  had  better  opportunities  than  I ; and  I have  not  seen 
any  recorded  observations  on  this  subject  by  cotemporaneous  investigators. 


* Larynx  and  Trachea,  1837,  Chapter  vii. 


SECTION  XIII — LARYNGOLOGY. 


69 


But  it  is  also  well  known  that  the  erysipelatous  nature  of  many  other  diseases  has  not 
i "been  discussed,  although  based  upon  evident  clinical  features.  I do  not  see  why  we 
I should  be  so  skeptical  as  to  the  primary  erysipelas  of  the  larynx. 

The  considerations  I have  urged  on  this  important  subject  seem  to  me  to  have  been 
appreciated  by  only  a few.  It  has  been  brought  to  my  notice  by  competent  observers 
that  epidemic  forms  of  a laryngeal  disease  have  ended  fatally  with  symptoms  of  an 
i acute  narrowing  which  could  be  referred  to  erysipelas.  Other  writers  believe  that  I 
have  denied  the  existence  of  a phlegmonous  laryngitis,  and  ascribed  to  me  a fault  wliich 
I have  not  committed.  The  phlegmonous  laryngitis  remains  the  same,  as  do  also 
the  acute  epiglottitis,  in  consequence  of  burnings,  the  primary  oedema  of  the  larynx 
i for  nephritis,  the  laryngitis  angioneurotica  of  Striibling,  etc. 

The  primary  erysipelas  of  the  larynx  has  a well  characterized  feature,  and,  in  order 
to  eliminate  every  doubt,  I decided  to  present  you,  dear  fellows,  the  argument,  and  in 
i the  following  short  propositions  all  that  clinical  observation  teaches  us: — 

1.  The  initial  symptoms  are  of  two  orders  : local  and  general.  The  first  compre- 
hends a difficulty  in  swallowing,  in  consequence  of  severe  pain,  with  changed  resonance 
of  the  voice,  like  that  which  happens  in  a common  angina  ; the  second  are  those 
referred  to  the  fever. 

2.  The  inspection  of  the  fauces  gives  a negative  result ; all  that  is  met  with  is  con- 
gestion of  the  posterior  wall  of  the  pharynx  ; on  the  contrary,  either  with  the  laryngeal 
mirror,  or  by  strongly  depressing  the  tongue,  the  epiglottis  appears  intensely  swollen. 

3.  Temperature  is  very  high — about  40°,  more  or  less. 

4.  The  local  symptoms  rapidly  increase.  Dysphagia  goes  as  far  as  complete  aphagia, 
and  soon  is  connected  with  difficulty  of  breathing  by  narrowing  of  the  larynx. 

A diligent  inspection  with  the  laryngoscope  shows  a contraction  which,  from  the 
back  of  the  tongue,  reaches  the  epiglottis,  the  ary-epiglottic  bands,  the  arytenoid  carti- 
lages. If  the  contraction  is  a moderate  one,  and  bound  to  the  orifice  of  the  vestibule, 
the  narrowing  is  supportable  with  life  ; but,  on  the  contrary,  if  it  is  considerable,  the 
patient  is  menaced  with  suffocation  or,  in  fact,  dies  suffocated. 

This  severe  danger  is  often  lessened  by  the  fact  of  a great  interest  for  the  diagnosis, 
i.  e.,  the  contraction  migrates;  the  parts  which  were  first  attacked  quickly  sink,  and 
those  which  were  healthy  become  tumefied  with  equal  rapidity. 

When  it  is  possible  to  see  the  internal  cavity  it  can  be  easily  observed  that  the 
swelling  is  preceded  by  an  intensive  congestion  (very  marked,  for  instance,  in  the 
inter-arytenoid  space).  Again,  with  the  tumefaction  is  associated  the  eruption  of 
blisters  full  of  serum,  which  burst,  and  then  the  exudation,  mixed  with  blood,  forms  a 
crust  on  the  surface.  It  is  also  possible  that  the  morbid  process  constitutes  a purulent 
infiltration,  or  a true  abscess. 

5.  Fever  is  relapsing,  of  anomalous  type.  A high  temperature  is  soon  followed  by 
defervescence.  From  40°,  the  temperature  goes  down  to  38°,  but  tbis  notwithstand- 
ing, the  local  symptoms  do  not  improve.  In  a short  time,  however,  without  any  regular 
period,  temperature  again  increases.  In  this  instance,  surely  the  local  lesion  is  in- 
creased, or  extended  in  the  neighborhood,  or  below,  to  the  lungs. 

6.  The  lymphatic  system  (groups  of  pre-tracheo-laryngeal  glands  and  pre-laryngeal 
ganglia)  is  something  distinctly  felt  with  the  palpation,  which  causes  pain. 

7.  After  several  such  oscillations,  the  disease  tends  to  three  different  character- 
istic issues  : first,  recovery,  in  consequence  of  a gradual  resolution  ; second,  death  by 
suffocation,  if  tracheotomy  is  not  performed  in  time  ; third,  death  by  collapse,  with 
or  without  signs  of  pulmonitis,  which  can  be  considered,  with  reason,  of  the  same 
nature. 

8.  Primary  erysipelas  of  the  larynx  can  assume  an  epidemic  character.  It  is  most 


70 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


probable  that  many  cases  of  severe  sore  throat  ending  fatally  with  suffocation  could 
have  been  recorded  in  this  chapter.  The  appearance  of  erysipelas  in  the  face,  in  the 
throat  or  elsewhere,  at  the  same  time  with  the  laryngitis,  or  after,  renders  the  diagnosis 
easier. 

9.  We  can  admit  two  forms  of  the  disease  : the  one  in  which  the  danger  is  repre- 
sented by  the  laryngeal  affection  itself ; the  second,  in  which  is  present  collapse,  or 
extension  to  the  lungs  takes  place.  In  old  people,  the  last,  and  death  in  consequence, 
is  the  most  common  issue  of  the  disease. 

10.  In  the  first  form  we  can  do  much  ; it  is  only  necessary  to  recognize  in  time 
the  affection.  In  such  a case,  ice,  internally  and  externally,  is  a portentous  remedy  ; 
surely  preferable  to  the  application  of  leeches.  Ice  can  be  supplied  with  the  adminis- 
tration of  calomel,  quinine  and  stimulants.  Spray  with  sublimate  solution  (1  to  2000) 
is  a good  remedy.  It  may  be  necessary,  if  the  dysphagia  is  severe,  to  feed  the  patient 
with  Dujardin-Beaumetz’  apparatus. 

11.  If,  in  spite  of  all  this,  the  narrowing  increases,  scarification  may  be  approved, 
and  after  tracheotomy  ; but,  as  the  migration  is  a common  phase,  it  is  not  advisable 
to  try  it  in  an  earlier  stage.  The  patient,  for  this  reason,  ought  to  be  overlooked 
with  rigor. 

12.  In  the  adynamic  form,  every  effort  is  useless.  The  disease  very  quickly  ends 
fatally,  or  before  the  remedy  has  time  to  act,  or  in  spite  of  its  good  effects,  as  for  the 
local  symptoms. 

DISCUSSION. 

Prof.  Stockton,  of  Chicago,  remarked — It  has  been  my  good  fortune  to  meet 
with  one  of  these  cases.  The  patient  was  a strong,  healthy  man,  who  caught  a severe 
cold,  as  he  supposed,  and  was  nearly  suffocated.  When  I was  hastily  summoned, 
I found  the  patient  lying  back  in  bed,  breathing  heavily,  the  temperature  1031°,  pulse 
140.  I found  that  the  patient  had  severe  rigors  that  morning.  The  pharynx  was 
normal,  the  larynx  intensely  congested,  and  there  were  several  blebs  on  the  epiglottis 
and  on  both  arytenoids.  The  ventricular  bands  were  so  swollen  that  they  covered 
both  vocal  cords,  and  I saw  that  something  must  be  done  at  once.  I did  not  have  any 
tracheotomy  tube,  and  went  to  my  office  to  get  one,  when  I thought  of  . a large 
O’Dywer  tube  that  I had,  and  resolved  to  try  it,  which  I did,  with  great  success. 
The  disease  gradually  extended  through  the  whole  upper-air  tract  and  over  the  upper 
part  of  the  face.  In  two  weeks  the  patient  made  a perfect  recovery. 

Dr.  Toeplitz,  of  New  York,  advocates  the  use  of  pilocarpine  (1  per  cent.)  sub- 
cutaneously applied.  He  has  not  seen  the  effect  of  this  remedy  in  cases  of  erysipelas 
of  the  larynx,  but  in  those  of  oedema  ; he  would  treat  erysipelas  of  the  larynx  on 
general  principles,  and  warns  against  the  use  of  O’Dywer’s  tubes  in  such  cases  as 
dangerous,  by  the  possible  production  of  gangrene  through  pressure. 

Dr.  W.  II.  Daly  stated  that  the  early  use  of  a most  extensive  mustard  plaster 
would  by  its  revulsive  action  tend  to  change  a laryngeal  erysipelas  into  a superficial 
one,  and  suddenly  rescue  a patient  from  imminent  danger  of  suffocation  from  oedema 
of  the  glottis.  Many  cases  of  erysipelas  of  the  larynx  are  really  treated  not  only  by 
the  specialist,  but  by  the  general  practitioner,  and  their  erysipelatous  nature 
unrecognized. 

Dr.  L.  N.  Beniiam,  of  Pittsburgh,  Pa.,  said — I was  greatly  pleased  with  the 
subject  matter  of  the  paper  just  read,  as  with  the  remarks  made  thereon  by  Dr. 


SECTION  XIII — LARYNGOLOGY. 


71 


Stockton.  Laryngeal  erysipelas,  with  pharyngeal,  for  they  practically  may  be  con- 
sidered one  and  the  same,  is,  according  to  my  observation,  seldom  recognized,  and 
not  sufficiently  appreciated  by  the  profession.  It  has  been  my  good  fortune  to  see 
eight  cases  well  marked  and  coufiued  simply  to  the  pharyngo-laryngeal  space;  they  all 
yielded  to  general  treatment,  combined  with  douches  of  hot  water,  and  without  enter- 
ing into  detail  of  symptoms,  I wish  to  call  attention  to  the  suddenness  with  which 
relief  would  come  to  patients  without  having  any  discharge  of  blood,  pus  or  mucus, 
commensurable  to  the  gravity  of  the  symptoms  present. 


72 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


FOURTH  DAY. 


Meeting  convened  at  3 P.  M. , the  President  in  the  chair. 

Prof.  W.  E.  Casselberry,  of  Chicago,  read  a paper  entitled — 

NASAL  FIBROMATA. 
fibrOmes  nasals. 

UBER  NASENFIBROME. 

BY  W.  E.  CASSELBERRY,  M.D., 

Of  Chicago,  111. 

Under  this  title  it  is  proper  to  include  only  neoplasms  of  a purely  fibrcros  or  pre- 
dominating fibrous  structure  which  originate  in  the  nasal  fosste  anterior  to  the  naso- 
pharynx. Tumors  in  this  situation  are  prone  to  assume  a compound  type.  Multiple 
nasal  polypi,  for  instance,  may  he  found  purely  myxomatous  in  the  anterior  nares,  but 
fibro-myxomatous  in  the  median  nasal  region  and  as  the  naso-pharynx  is  approached. 
The  fibro-sarcoma  is  another  combination  occurring  iu  varying  proportions  of  fibrous 
or  sarcomatous  elements.  The  scope  of  this  paper  will  not  permit  of  consideration  of 
these  compound  types,  notwithstanding  their  intimate  relationship  to  the  fibromata. 
Likewise  of  fibromata  which  originate  in  the  neighboring  sinuses,  and  which  involve 
the  nose  only  secondarily,  must  such  meagre  mention  suffice  as  is  essential  to  the  eluci- 
dation of  the  nasal  growths  proper. 

Current  literature  of  the  last  decade  has  teemed  with  reports  of  cases  of  naso-pharyn- 
geal  fibromata,  recounting  the  various  operative  and  preliminary  operative  procedures 
for  their  removal,  including  Langenbeck’s  resection  of  the  superior  maxilla,  Fergusson's 
resection  of  the  same,  Nelaton’s  operation,  Gussenbauer’s  subperiosteal  resection  of  the 
hard  palate,  Rouge’s  operation  and  the  recent  method  of  Furneaux  Jordan. 1 Nor  have 
rhinologists  failed  to  emphasize  the  advantages  of  the  intra-nasal  or  intra-naso-pharvn- 
geal  galvano-cautery  method.  I will  urge  in  nasal  cases  the  use  of  similar  means  in 
preference  to  the  other  graver,  disfiguring  and  sometimes  fatal  operations. 

Fibromata  originating  primarily  in  the  nose  anterior  to  the  naso-pharynx  are  com- 
paratively rare.  The  Internationales  Centralblatt  fur  Laryngologie,  Rhinologie  und  Ver- 
viandte  Wissenschaftrn,  a journal  of  abstracts  of  all  current  literature  pertaining  to  these 
subjects,  does  not  contain  the  report  of  a single  case  during  the  past  three  years.  One 
case  of  fibro-sarcoma  which  may  have  originated  as  a fibroma  is  reported  therein.  Iu 
the  Annalcs  des  Maladies  de  V Oreille,  du  Larynx , du  Kcz,  et  du  Pharynx,  from  1875  to 
date,  is  found  but  one  other  case  which  can  possibly  be  included  iu  this  category. 
Hopman,2  of  Cologne  (248  cases),  and  Schmiegelow,  of  Copenhagen  (17  cases),  have, 
together,  reported  205  cases  of  nasal  neoplasm,  of  which  there  were  121  myxomata,  03 


1 Internationales  Centralblatt  fur  Laryngologie,  Rhinologie,  etc.  Jahrgang  II,  S.  207. 

a Internationales  Centralblatt  fur  Laryngologie,  Rhinologie,  Vol.  II,  429,  etc. 


SECTION  XIII — LARYNGOLOGY.  73 

polypoid  hypertrophy  of  the  turbinated  bodies,  24  papillomata,  one  lupus  and  one 
< sarcoma,  the  series  containing  no  cases  of  fibromata.  Yet  their  occasional  occurrence 
has  been  recognized  probably  from  the  time  of  Hippocrates,  who  had  a large  experience 
in  connection  with  nasal  polypi. 

In  the  case  of  hard  polypi,  Hippocrates,1  cited  by  Mackenzie,  directed  that  the 
.1  nostril  should  be  slit  open  in  order  that  the  tumor  might  be  thoroughly  extirpated,  and 
the  roots  afterward  destroyed  by  the  hot  iron.” 

Celsus2  treated  polypi  in  various  ways,  but  he  strongly  disapproved  of  meddling 
I with  the  harder  tumors,  which  he  considered  maliguant. 

Recent  works  on  the  throat  and  nose  treat  briefly  of  the  subject.  Stoerk  3 mentions 
■ fibromata  as  originating  from  the  submucous  structures.  Cohen4 *  briefly,  but  lucidly, 
j describes  the  neoplasm,  and  mentions  its  comparative  infrequency.  Sajous,6  mentions 
the  roof  as  its  favorite  site  in  the  nose,  but  remarks  that  cases  have  been  reported  in 
i which  fibrous  polypi  sprang  from  the  septum,  the  inferior  turbinated  bones,  and  even 
the  floor  of  the  nose.  He  further  remarks  upon  the  rarity  of  its  primary  occurrence. 

Wagner6  writes  : “Fibromata  may  develop  in  any  portion  of  the  nasal  cavity,  the 
floor  of  the  fossae,  the  turbinated  bones,  or  lateral  walls,”  etc.,  and  he  reports  two  cases. 

Robinson7  thinks  it  so  unusual  in  the  nose  and  so  usual  in  the  naso-pharynx  that 
he  considers  the  difference  in  location  a point  in  diagnosis  between  fibroma  and 
myxoma. 

Morell  Mackenzie8  has  reported  a single  case  of  his  own,  and  two  others  probably 
fibromata,  and  remarks,  in  this  connection  : ‘ ‘ Though  fibrous  polypus  of  the  naso- 
pharynx is  not  unlrequently  met  with,  this  form  of  tumor  extremely  seldom  originates 
in  the  nose  itself,  the  only  case,  so  far  as  I am  aware,  in  which  such  a growth  has  been 
proved  to  exist  being  one  of  my  own.”  “ There  are,  however,  two  other  instances  in 
which  there  is  every  reason  to  believe  the  tumors  were  fibromatous.” 

It  seems  probable  that  nasal  fibromata  are  in  reality  more  numerous  than  the  few 
cases  recently  reported  would  indicate,  and  this  probability  should  tend  to  enhance  our 
interest  in  the  subject. 

Growths  in  the  nose  and  naso-pharynx,  in  a measure,  correspond  in  type  to  the  struc- 
tural elements  of  the  tissue  from  which  they  originate.  The  nasal  mucous  membrane 
consists  of  two  layers,  a superficial  mucous  stratum,  which  is  covered  by  epithelium, 
and  a deep  fibrous  layer,  which  has  the  position  and  functions  of  periosteum  and  peri- 
chondrium. In  the  upper  or  olfactory  tract  these  two  strata  are  closely  adherent, 
while  in  the  lower  or  respiratory  tract  they  are  separated  hy  variable  quantities  of  con- 
nective tissue.9 

The  fibrous  layer  has  been  shown  by  Panas,10  cited  by  Mackenzie,  to  be  especially 
abundant,  and  more  densely  fibrous  at  the  upper  and  posterior  part  of  the  septum  and 
in  the  immediately  adjoining  space  on  the  base  of  the  skull,  and  hence  the  frequency 
of  naso-pharyngeal  fibromata,  while  in  the  anterior  nares  it  is  least  abundant,  the  super- 

1 “ Morbis,”  lib.  ii,  Lettre’s  Ed.,  Paris,  1851,  Vol.  ii,  p.  51.  Mackenzie,  “Diseases  of  the 
Throat  and  Nose.”  Wood’s  Ed.,  Vol.  ii,  p.  245. 

2 “ De  Comp.  Pharm.  Sec.  Locos.,”  Lib.  in ; Cap.  in.  Mackenzie,  loc.  cit. 

3 “ Klinik  der  Krankheitcn  des  Kehlkopfs,  der  Nase  und  des  Rachons,”  S.  90. 

4 “ Diseases  of  the  Throat  and  Nasal  Passages,”  1880,  p.  392. 

6“  Diseases  of  the  Nose  and  Throat,  1885,”  p.  146. 

* “ Diseases  of  the  Nose,”  1884,  p,  134. 

7 “Nasal  Catarrh  and  Allied  Diseases,”  1885,  p.  256. 

6 “ Diseases  of  the  Throat  and  Nose.”  American  Ed.,  Vol.  ii,  p.  275. 

9 Mackenzie.  Am.  Ed.,  Vol.  ii,  page  238. 

Hull,  de  la  Soc.  de  Ghir.,  1873.  Mackenzie,  “ Diseases  of  the  Throat  and  Nose.”  Wood’s 

Ed.,  Vol.  ii,  page  386. 


L 


74 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ficial  mucous  layer  predominating,  and  hence  the  more  common  occurrence  in  this 
location  of  the  myxomata. 

Further,  between  these  sites,  around  the  posterior  nares,  the  membrane  presents  a 
kind  of  transitional  form,  and  growths  in  this  situation  are  likely  to  present  a corres- 
ponding fibro-mucous  type. 

This  observation,  in  connection  with  the  assertion  of  Stoerk, 1 that  polypi  arising 
from  the  mucosa  (superficial  layer)  are  of  mucous  structure,  while  those  arising  from 
the  sub-mucosa  or  periosteum  are  fibrous,  affords  a reasonable  explanation  of  the  com- 
parative infrequency  of  true  nasal  fibromata. 

True,  the  attachments  of  ordinary  myxomata  are  sometimes  traceable  to  the  perios- 
teum or  to  the  bone,2  hut  it  is  probable  that  they  have  first  originated  in  the  superficial 
mucosa  and  only  subsequently  penetrated  to  the  deeper  structures. 

Nelaton,  cited  by  P.  Koch,3  has  advanced  the  opinion  that  fibrous  polyps  of  the 
nose  are  never  of  a primary  nature,  but  that  they  always  proceed  from  neighboring  sin- 
uses, e.  g .,  the  antrum  of  Highmore,  etc.  A practical  refutation  of  this  theory  is  fur- 
nished by  a case  reported  by  Gerdy, 4 in  which,  on  post-mortem  examination,  a fibroma 
was  found  to  he  attached  to  the  posterior  part  of  the  vault  of  the  left  nasal  fossa. 

This  tumor  was  not  examined  microscopically,  but  from  its  macroscopic  appearance 
there  is  every  reason  to  believe  that  it  was  a fibroma,  and  it  is  so  classed  by  Mackenzie. 5 

Fibromata  may  arise  from  any  part  of  the  nasal  cavities.  The  vault,  especially  its 
posterior  portion,  is  the  favorite  site,  as  here  is  found  in  greater  abundance  the  fibrous 
stratum  from  which  they  primarily  originate,  but  the  turbinated  bodies,  the  cribriform 
plate  of  the  ethmoid  bone,  the  septum  and  the  floor  of  the  nose, 6 may  furnish  points  of 
origin. 

More  or  less  extensive  secondary  adhesions  may  form  in  the  course  of  the  expansion 
of  the  growth,  as  the  result  of  friction  and  pressure,  so  that  it  is  sometimes  difficult  to 
determine  the  original  point  of  attachment. 

Of  the  accessory  cavities  the  antrum  of  Highmore  is  a favorite  site  of  origin,  the 
fibromata  of  which  become  very  large,  and  encroach  secondarily  upon  the  cavities  of  the 
nose  and  orbit,  and  next  in  order  are  the  frontal  sinuses,  tumors  from  which  extend 
into  the  same  cavities. 

The  setiological  factors  in  the  development  of  nasal  fibromata  are  not  definitely 
known,  but  a local  irritation  from  traumatism  may  serve  to  excite  a hyperplasia  of  the 
fibrous  elements,  as  in  one  case  of  fibroma  of  the  septum,  which  was  directly  attribut- 
able to  a blow  on  the  nose.  In  other  instances  a localized  perversion  of  the  chronic 
hypertrophic  inflammatory  process  may  act  as  the  exciting  cause  by  stimulating  the 
fibrous  elements  to  unusual  proliferation. 

Both  sexes  and  all  ages  seem  equally  liable.  In  this  respect  the  disease  differs  from 
naso-pharyngeal  fibroma,  of  which  Lincoln7  collates  38  genuine  cases,  all  of  them  males 
under  twenty-five  years  of  age,  Nelaton, 8 cited  by  Mackenzie,  knew  of  no  example 
of  naso-pharyngeal  fibroma  becoming  developed  in  a female  of  any  age  or  in  a male 
over  thirty-five. 


1 “Die  Krankheiten  der  Nase,”  1880,  S.  90. 

2 Zuckerkandl,  cited  by  Mackenzie,  “ Diseases  of  the  Throat  and  Nose,”  American  Ed.,  Vol. 
II,  page  362. 

8 P.  Koch  (Luxemburg)  Int.  Centralb.  f.  Laryn.  und  Rhinol.,  II,  page  256. 

4 “ Des  Polypes  et  do  leur  Traitement,”  Paris,  1833,  page  19. 

6 “ Diseases  of  the  Throat  and  Nose,”  Wood’s  Ed.,  Vol.  ii,  page  264. 

• Sajous,  “ Diseases  of  the  Nose  and  Throat,”  page  146.  7 Loc.  cit. 

8 “ Rapport  sur  le  Progres  de  la  Chirurgie,”  Paris,  1867,  p.  325.  Mackenzie,  “ Diseases  of 

the  Throat  and  Nose,”  Vol.  II,  p.  497,  Am.  Ed. 


SECTION  XIII — LARYNGOLOGY.  75 

Of  six  cases  of  pure  nasal  fibroma  collected  in  this  paper,  three  were  females,  one  of 
hirty-five  years,  one  of  thirty-eight  years,  and  one  of  fifty  years  of  age. 

The  rapidity  of  growth,  as  indicated  hy  the  duration  of  the  symptoms  up  to  the 
ime  of  operation,  averages  about  two  years. 

The  early  symptoms  are  those  of  a catarrhal  nature,  followed  hy  obstruction  and  dis- 
ention  of  the  fossa.  Its  development  continues,  to  the  detriment  of  hones  and  cartil- 
iges  that  may  he  in  the  way.  These  are  absorbed,  enveloped  and  rent  asunder,  the 
leoplasm  penetrating  into  fissures,  accessory  sinuses,  and  neighboring  cavities. 

The  bridge  of  the  nose  becomes  flattened,  the  eyes  bulged  forward  and  the  cheek 
swollen,  the  whole  constituting  the  hideous  deformity  known  as  “frog-face.”  Fre- 
. pient  and  dangerous  attacks  of  epistaxis  may  proceed  from  surface  ulceration.  Exten- 
sion upward  may  open  the  cranial  cavity. 

A probable  diagnosis  is  not  difficult.  Its  appearance  in  situ  differs  much  from  that 
: if  the  mucous  polyp.  It  is  not  multiple,  but  may  be  lobulated.  The  base  is  broad, 
she  color  is  dark  red,  there  is  no  translucency,  and  it  is  firm  and  resistant  to  pressure 
ay  a probe.  It  is  more  difficult  to  distinguish  it  thus  from  fibro-sarcoma  and  sarcoma. 
The  microscope  is  the  only  means  of  positive  diagnosis. 

Fibrous  tumors  in  this  situation  present  the  ordinary  pathological  characters  of  fibro- 
nata  in  general.  In  consistence  they  vary,  being  sometimes  very  firm  and  dense,  and 
;;  it  other  times  softer  and  more  succulent.  The  fibres  which  constitute  the  chief  part 
if  the  growth  are  grouped  in  bundles  of  various  sizes,  or  are  simply  closely  interlaced 
ind  devoid  of  definite  arrangement.  A very  few  minute  cells,  either  round  or  spindle- 
ihaped,  may  be  present  among  the  fibres,  or  in  larger  numbers  around  the  blood  ves- 
sels. The  vessels  are  not  usually  numerous,  but  it  is  probable  that  the  tumors  or  por- 
tions of  them  may  partake  at  times  of  the  erectile  structure  of  the  turbinated  bodies. 
A smooth,  fibrous  capsule  usually  envelops  the  whole. 

Concerning  the  prognosis,  nasal  fibroma  tends  to  degenerate  into  sarcoma  when  it  is 
I incompletely  removed,  or  even  without  any  interference.  There  is  a tendency  to  recur- 
rence after  removal,  although,  if  thoroughly  extirpated  and  the  base  cauterized  to  the 
bone,  the  prognosis  should  be  good. 

I have  tabulated  and  appended  the  records  of  eight  cases,  including  one  of  my  own, 
which  is  published  for  the  first  time,  and  which  I will  relate  in  detail. 

Case. — Mrs.  R. , native  of  Canada,  aged  about  thirty-eight  years,  first  had  a nasal 
polypus,  described  as  an  ordinary  myxoma,  removed  from  the  left  nasal  fossa,  about  ten 
'years  ago.  She  remained  well  for  five  years,  and  then  again  noticed  gradually  increas- 
ing obstruction,  and  later  a dark,  reddish  mass  presenting  itself  at  the  left  anterior  nasal 
' aperture. 

Four  years  ago  she  submitted  to  operation  under  chloroform.  The  operation  was  a 
failure,  only  a few  small  pieces  being  removed  by  means  of  forceps  and  without  the  aid 
of  artificial  illumination.  Severe  hemorrhage  was  occasioned  at  the  time  and  continued 
intermittingly  for  weeks.  No  relief  was  afforded. 

She  declined  further  interference  until  February,  1886,  at  which  time  she  came  under 
the  observation  of  Dr.  W.  F.  Coleman  and  Dr.  A.  P.  Gilmore,  of  Chicago,  through 
j whose  kindness  I have  a portion  of  the  record.  The  left  nostril  was  much  distended, 
'showing  evidence  of  commencing  frog-face,  and  the  fossa  anteriorly  was  thoroughly 
filled  in  all  directions  by  a firm,  elastic  tumor  which  projected  slightly  from  the  anterior 
: aperture.  There  was  no  undue  prominence  over  the  antrum  of  Highmore,  nor  encroach- 
ment upon  the  orbit. 

These  gentlemen  operated  skillfully  by  means  of  the  galvano-cautery.  Efforts  to 
include  the  neoplasm  in  a snare  failed,  on  account  of  its  large  size,  tight  fit  and 
numerous  adhesions,  so  its  lower  portion  was  slit  up  by  the  knife  electrode,  some 
adhesions  separated  in  like  manner  and  a large  section,  perhaps  one-lialf  of  the 


76 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


tumor,  extracted  by  means  of  forceps.  The  operation  was  necessarily  prolonged, 
painful  and  bloody. 

Through  the  courtesy  of  Dr.  Coleman,  the  case  was  now  referred  to  me. 

Status  Preesens. — Examination,  about  ten  days  subsequent  to  the  operation  just 
described,  March  4th,  1886.  The  left  half  of  the  external  nose  is  decidedly  more  promi- 
nent than  the  right.  The  left  nasal  fossa  above  the  line  of  the  inferior  turbinated  body 
is  completely  filled  by  a firm,  elastic,  irregularly-lobulated  neoplasm.  No  middle  tur- 
binated body  is  discernible,  its  position  being  occupied  by  tumor.  The  inferior  meatus 
is  free,  corresponding  to  the  portion  of  the  growth  already  removed. 

The  anterior  two- thirds  of  the  septum  narium  has  been  pressed  far  over  to  the  right, 
narrowing  the  right  fossa  and  enormously  increasing  the  capacity  of  the  left  chamber. 

Rhinoscopic  inspection  posteriorly  shows  the  naso-pharynx  to  be  approximately 
normal.  Only  a faint  outline  of  the  tumor,  located  well  forward,  can  be  seen  through 
the  left  choana.  The  posterior  portion  of  the  septum  is  in  the  median  line. 

First  Operation , March  10th,  1886. — The  affected  nostril  was  first  thoroughly  cleansed 
by  cotton  swabbing  and  by  means  of  a condensed  air  spray  of  Dobell’s  solution.  The 
parts  were  illuminated  by  the  ordinary  method  of  reflected  gas  rays  projected  through 
the  anterior  aperture,  which  was  widely  dilated  by  a bivalve  speculum.  Complete  local 
anaesthesia  of  the  entire  nostril  was  induced  by  hydrochlorate  of  cocaine,  applied  in 
the  form  of  a spray  of  a five  per  cent,  solution,  repeated  three  or  four  times  at  intervals 
of  three  minutes,  followed  by  a ten  per  cent,  solution  on  cotton,  introduced  and  allowed 
to  remain  in  contact  with  the  fibroma  for  three  minutes. 

I employed  Flemming’s  gal  vano-cautery  ecraseur,  as  devised  by  Seiler  and  which  I 
exhibit,  which  consists  of  a universal  handle  into  which  is  inserted  a pair  of  parallel 
tubes  threaded  with  wire.  The  ends  of  the  wire  pass  through  eyelets,  one  on  each  side 
of  the  wheel,  in  the  axle  bar  of  the  windlass,  which  is  inserted  into  a slot  in  the  handle, 
so  located  that  while  holding  the  handle  the  loop  can  be  wound  in  on  the  windlass  by 
means  of  the  thumb. 

I substituted  steel  or  tempered  iron  wire  (piano  wire)  for  the  platinum  usually 
employed.  Platinum  is  devoid  of  resiliency,  a property  which  enables  the  ecraseur 
loop  of  steel  wire  to  retain  or  regain  its  contour  after  contact,  when  one  of  platinum 
would  remain  permanently  indented.  The  steel  loop  offers  some  resistance  to  tissue 
against  which  it  is  pressed,  thus  facilitating  envelopment  of  the  part.  The  steel  wire 
is  sufficiently  tenacious  and  takes  the  glow  from  the  battery  as  well  as  platinum,  but  a 
fresh  piece  must  be  used  at  each  application.  Before  threading  the  parallel  tubes  it  is 
well  to  withdraw  the  temper  from  the  ends  of  the  wire  by  heating  them  to  redness,  as 
the  portion  thus  rendered  ductile  will  wind  more  easily  around  the  windlass. 

I would  catch  in  the  ecraseur  the  most  easily  enveloped  lobule  or  corner  of  the 
growth,  then  connect  the  battery  by  running  down  the  treadle  with  my  foot  and  at  the 
same  time  wind  in  the  loop,  thus  severing  without  pain  and  with  little  or  no  hemor- 
rhage a cubic  centimetre  or  more  of  the  growth.  By  a repetition  of  the  process,  three 
or  four  such  pieces  would  be  removed  in  a sitting. 

Occasionally  it  became  necessary  to  make  a preliminary  incision  into  the  substance 
of  the  tumor  with  the  knife  electrode,  in  order  to  prepare  a place  for  the  wire,  or,  by 
the  same  means,  to  detach  an  adhesion,  that  the  ecraseur  might  take  hold. 

The  operations  were  repeated  weekly,  the  patient  using  a cleansing  spray  in  the 
interval.  They  might  have  been  performed  more  frequently,  every  day  or  every  alter- 
nate day,  for  a time,  thus  shortening  the  duration  of  the  treatment,  but  the  slower 
method  sufficed,  and,  for  good  reasons,  was  preferable  in  this  case.  During  the  course 
of  some  weeks  the  growth  was  thus  followed  up  to  its  primary  attachments,  which 
extended  along  the  horizontal  plate  of  the  ethmoid  bone  backward  to  the  anterior 
surface  of  the  body  of  the  sphenoid. 


SECTION  XIII — LARYNGOLOGY. 


77 


I regard  the  posterior  portion  of  the  vault — i.  e.,  vault  of  nose,  not  of  pharynx, 
ncluding  the  anterior  perpendicular  surface  of  the  sphenoid  bone — as  the  point  of 
•rigin  of  the  tumor,  the  base  of  which  extended  thence  anteriorly  along  the  cribriform 
date  of  the  ethmoid  bone,  becoming  adherent,  at  the  same  time,  to  portions  of  the 
aiperior  turbinated  body  and  the  walls  of  the  ethmoid  cells. 

The  absence  of  the  middle  turbinated  body,  which  had  been  reduced  to  a rudiment 
)y  absorption  from  pressure,  permitted  a more  brilliant  illumination  of  the  parts  above, 
i ind  not  only  facilitated  operation,  but  enabled  me,  with  certainty,  to  follow  the  tumor 
jo  its  base.  After  the  removal  of  all  portions  which  could  be  included  in  the  snare,  I 

> jauterized  the  base  by  means  either  of  the  galvano-cautery  point,  knife  or  moxa  elec- 
trode, causing  the  instrument  to  penetrate  each  time  to  the  bone.  This,  also,  I did 
i small  part  at  a time,  fearing  to  produce  much  inflammatory  action,  on  account  of 

I the  immediate  proximity  to  the  cerebral  meninges  through  the  cribriform  plate  of 
ithe  ethmoid  bone.  I cauterized  everything  which  had  any  appearance  of  fibroma, 
preferring  to  touch  that  which  was  not  fibroma  rather  than  to  leave  untouched  that 
which  was. 

At  the  end  of  six  months  the  tumor  seemed  thoroughly  eradicated.  The  fossa 
above  the  inferior  turbinated  body  was  unoccupied  by  anything  but  rudiments  of  the 
middle  and  superior  turbinated  bodies,  the  view  of  the  vault  in  all  directions  being 
uninterrupted.  She  still  remained  under  observation. 

At  the  end  of  nine  months  a recurrent  tumor,  the  size  of  a small  bean,  was  discov- 
ered attached  to  the  lateral  wall  just  above  the  anterior  end  of  the  inferior  turbinated 
body.  I think  a point  of  secondary  attachment  here  had  escaped  cauterization  and 
i re-developed,  for,  on  account  of  the  recession  of  the  lateral  wall,  it  was  at  a point  diffi- 
cult of  illumination  and  access,  being  just  within  the  anterior  aperture,  but  around  the 

> corner  as  it  were.  This  tumor  was  removed  by  the  same  means. 

At  the  end  of  seventeen  months  there  is  no  appearance  of  any  further  recurrence, 
although,  in  view  of  the  known  tendency  to  relapse  in  such  cases,  she  cannot  even  yet 
be  considered  wholly  free  from  liability  to  re-development. 

I am  indebted  to  Dr.  Elbert  Wing,  Demonstrater  of  Pathology  in  the  Chicago  Medical 
College  and  Pathologist  to  Cook  County  Hospital,  for  the  microscopic  examination  which 

{demonstrated  the  tumor  to  be  a typical  fibroma.  This  result  was  also  confirmed  by  my 
own  examination.  The  pieces  removed,  in  the  aggregate,  would  about  equal  in  size  a 
small  hen’s  egg. 

Treatment  in  General. — Of  the  seven  other  cases  appended,  in  No.  1 attempts  at 
removal  by  ligature  and  forceps  failed,  and  were  followed  by  an  attempt  to  cut  through 
the  base  of  the  polypus  with  a bistoury,  which  resulted  in  death  from  hemorrhage.  The 
i treatment  in  Case  No.  2,  is  not  stated.  In  Case  No.  3 the  tumor  projected  posteriorly 

!and  was  removed  by  forceps  introduced  through  the  naso-pharynx.  In  three  cases,  Nos. 

4,  5 and  7,  external  operations  were  performed  to  give  access  to  the  tumor  ; in  No.  4,  a 
I crucial  incision  was  made  over  the  left  side  of  the  nose  and  the  nasal  bones  lifted  out ; 

in  No.  5,  the  nasal  columns  and  septum  were  divided  and  the  nose  turned  up  ; in  No. 
i 7 ( fibro-sarcoma),  a median  incision  was  made  through  the  bridge  of  the  nose.  All  of  these 
operations  must  have  been  disfiguring  and  somewhat  dangerous.  In  Case  No.  G (possibly 
fibro-myxoma)  the  tumor  was  successfully  removed  piecemeal,  in  fifteen  sittings,  by  a 
cold-wire  snare.  The  advantages  of  the  intra-nasal  galvano-cautery  method,  as  detailed 
in  my  own  case,  are  sufficiently  obvious. 

General  anaesthesia  is  unnecessary,  and  the  consequent  shock  and  dread  of  operation 
are  avoided.  There  is  no  external  disfigurement,  no  dangerous  hemorrhage,  aud,  under 
cocaine,  no  pain.  My  patient  would  sit  in  the  operating  chair  and  have  piece  after 
piece  removed  without  manifesting  even  discomfort. 


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NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


It  is  certainly  a more  brilliant  operation,  when  possible,  to  encircle  the  entire  tumor 
and  remove  it  in  toto  at  one  sitting,  but  in  case  of  the  larger  fibromata  this  will  usually 
be  impracticable,  on  account  of  the  impaction  of  the  mass  into  the  inequalities  of  the  \ 
nasal  fossa,  and  the  formation  of  adhesions.  Moreover,  the  slower  method  of  removal  i 
piece  by  piece  offers  the  advantage  of  greater  deliberation,  implying  also,  as  it  does  1 
greater  precision,  for,  when  sufficient  oozing  occurs  to  interfere  with  the  view,  further  ; 
action  is  postponed  until  the  next  time,  and  by  repeated  sittings  the  patient  grows 
accustomed  to  manipulation,  and  learns  to  assist  the  surgeon  by  holding  correctly.  I 
The  surgeon,  also,  in  turn,  by  repeated  opportunities  to  study  the  parts,  becomes 
so  familiar  with  the  area  over  which  he  is  working,  that  he  can  readily  trace  out  all  the 
ramifications  of  the  growth. 

No  undue  inflammatory  reaction  follows  the  operations,  and  sepsis  can  be  avoided 
by  thorough  cleansing  of  the  nostril  by  means  of  an  antiseptic  spray. 

In  the  case  of  Mrs.  R.,  a lady  of  refinement,  to  whom  any  facial  disfigurement 
would  have  been  exceedingly  abhorrent,  the  galvano-cautery  used  in  this  manner  was 
the  one  means  which  rendered  a formidable  external  operation  avoidable.  The  nature 
of  the  case  would  have  precluded  an  effective  intra-nasal  use  of  the  cold  wire  snare, 
ligature,  forceps,  or  chemical  caustics. 

An  agent  capable  of  effecting  such  brilliant  results  naturally  engenders  an  enthu- 
siam  which  is  liable  to  lead  to  its  abuse,  and  a word  of  caution  is  not  unnecessary 
in  this  respect.  Accurate  diagnosis,  precise  indications  for  its  use,  and  a certain 
amount  of  skill  on  the  part  of  the  operator,  are  essentials  to  the  j udicious  employment 
of  the  galvano-cautery.  And  it  must  not  be  supposed  that  all  cases  will  be  susceptible 
of  this  means  of  cure.  Enormous  size  and  penetration  into  accessory  cavities  may 
render  it  ineffective. 

Electrolysis  has  been  successfully  employed  in  naso-pharyngeal  fibroma,  and  it  may 
prove  serviceable  in  nasal  fibroma  of  enormous  growth,  at  least  to  reduce  the  size  :o 
such  a point  that  the  galvano-cautery  can  cope  with  it,  thus  again  avoiding  an  external 
operation. 


DISCUSSION. 

Mr.  Lennox  Browne,  of  London,  congratulated  the  author  of  the  paper  on  the 
success  of  his  case,  and  conceived  that  in  the  present  state  of  knowledge  no  surgeon, 
certainly  no  specialist,  would  think  of  any  but  intra-nasal  treatment,  and  probably 
the  electro-cautery  would  be  the  most  generally  serviceable  method  for  these  as  for 
other  neoplasms  of  firm  structure.  Mr.  Browne  mentioned  that  the  instrument  em- 
ployed by  the  author  was  in  no  respect  different  from  that  used  by  him  nearly  twelve 
years  ago. 

Dr.  M.  F.  Coomes,  of  Louisville,  Ky. , said  that  he  desired  to  thank  Dr.  Cassel- 
berry for  the  excellent  paper,  and  further  said  that  he  had  seen  such  a case  some  eight 
years  since,  in  the  person  of  a stout  laborer.  The  tumor  protruded  at  the  anterior 
naris,  the  characteristic  frog-face  rapidly  developing.  The  tear  passages  were  occluded, 
the  tears  flowing  over  the  cheek.  He  had  suffered  from  severe  epistaxis.  He  refused  i 
to  be  operated  on  until  he  had  almost  lost  his  life  by  epistaxis.  He  was  chloroformed  I 
and  the  ala  of  the  nose  raised  by  cutting  through  the  soft  tissues,  carrying  the  incision  i 
up  to  the  hard  tissues  (to  the  bones).  An  attempt  to  remove  the  growth  by  grasp- 
ing it  with  a pair  of  strong  forceps  and  making  strong  traction  failed.  The  pedicle 
of  the  growth  was  finally  severed  by  the  use  of  the  scissors,  when  it  was  seized  with 
the  forceps  and  by  strong  traction  was  removed.  The  tumor  weighed  nearly  one 
ounce  when  cleansed.  There  was  severe  hemorrhage  following  the  removal  of  the 
tumor,  which  was  attached  to  the  upper  part  of  the  middle  and  the  inferior  portion 


SECTION  XIII LARYNGOLOGY. 


81 


i of  the  upper  turbinated  bones.  The  patient  made  a good  and  rapid  recovery.  I do 
• not  think  there  was  a return  of  the  disease,  as  the  patient  passed  from  under  my 
■ observation. 

Prof.  E.  Eletcher  Ingals,  of  Chicago,  said  he  had  never  seen  a pure  and 
simple  nasal  fibroma,  but  had  seen  two  cases  in  which  the  tumor  was  attached  both 
i in  the  naso-pharynx  and  the  naris,  and  he  apprehended  that  their  removal  would  not 
( be  materially  different  from  the  nasal  fibroma.  He  thought  that  his  friend  had  been 
fortunate  in  having  a case  in  which  he  could  operate  without  pain,  for  in  the  cases 
in  which  he  had  removed  the  fibrous  mass  from  the  naris  he  had  found  it  impossible 
to  anaesthetize  the  part  so  that  the  patient  would  not  suffer  considerable  pain,  and 
this  although  he  was  thoroughly  familiar  with  the  application  of  cocaine,  and  had 
used  it  very  often.  He  thought,  also,  that  the  absence  of  hemorrhage  in  the  case  re- 
ported was  the  author’s  good  fortune,  and  not  a rule  that  would  apply  to  all  cases. 
He  wished  to  inquire  about  the  steel  wire  used  by  the  author  with  the  galvano-cau- 
tery.  He  had  the  same  kind  of  6craseur,  but  he  had  always  found  that  the  steel 
wire  heated  with  much  greater  difficulty  than  the  platinum. 

Dr.  Stockton,  of  Chioago,  said — I simply  rise  to  make  a suggestion,  namely, 
that  the  platinum  and  iridium  wire  be  used  instead  of  pure  platinum,  because  the 
platinum  and  iridium  is  much  stiffer  and  has  more  spring,  also  offers  more  resistance, 
consequently  heats  more  rapidly. 

Prof.  W.  E.  Casselberry  closed  the  discussion  by  remarking — I feel  grateful 
for  the  very  friendly  manner  in  which  this  paper  has  been  received.  In  reply  to  Mr. 
Lennox  Browne,  I would  say  that  galvano-cautery  snares  are  constructed  much  on  the 
[ same  principle,  and  when  a foreign  instrument  is  modified  in  this  country,  an  enter- 
i prising  instrument  maker  is  sure  to  advertise  it  as  the  device  of  its  modifier.  In 
i reference  to  the  painlessness  of  cauterization  in  the  nose,  people  differ  in  suscepti- 
bility both  to  cocaine  and  pain,  but  in  the  case  reported  the  cocaine  was  applied  in 

(strong  solution,  both  by  spray  of  five  to  ten  per  cent.,  and  repeated  applications  on 
cotton  of  twenty  to  twenty-five  per  cent. , allowing  the  cotton  applicator  to  remain 
| within  the  naris,  in  contact  with  the  parts,  for  from  three  to  five  minutes.  Other 

(cases,  perhaps,  when  less  thoroughly  cocainized,  feel  the  cautery  more.  To  avoid 
any  possible  toxic  effect,  strong  applications  of  cocaine  should  never  be  used  until 

I the  susceptibility  of  the  patient  has  been  tested.  I have  no  means  of  measur- 
ing minutely  the  comparative  ease  of  glow  of  the  steel  and  platinum  wire.  To  me, 
for  all  practical  purposes,  they  take  the  glow  the  same.  I have  even  had  to  exer- 
cise more  care  in  order  to  prevent  my  steel  loop  from  burning  up  than  in  using  the 
platinum  wire.  Hemorrhage  is  liable  to  succeed  the  cautery,  but  less  so  than 
after  other  methods  of  operating.  The  iridium  and  platinum  wire  i3  a useful 
) suggestion. 


Vol.  IV— 6 


82 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Paper  read  by  Dr.  John  0.  Roe,  of  Rochester,  N.  Y.,  entitled — 


LARYNGEAL  CHOREA  (CHOREA  LARYNGIS). 

CHOREE  DU  LARYNX. 

CHOREA  LARYNGIS. 

BY  JOHN  O.  ROE,  M.D., 

Rochester,  N.  Y. 


In  pre-laryngoscopic  literature  we  find  records  of  many  cases  of  peculiar  spasmodic 
conditions  of  the  larynx  attended  by  a cough  of  a barking,  howling,  bellowing,  crow- 
ing or  musical  character,  which  were  considered  due  to  hysterical  or  psychical  dis- 
turbance, but  which  were  unquestionably  in  many  instances  simply  cases  of  chorea  of 
the  larynx.  The  first  to  apply  the  term  laryngeal  chorea  to  a peculiar  manifestation 
in  the  larynx  was  Lac  de  Bosredon,  of  Bordeaux,  in  1857. 1 He  reported  the  case  of  a 
boy  attacked,  during  inspiration,  by  a peculiar  crowing  cough  like  that  of  a cock,  ’j 
which  followed  an  attack  of  bronchitis.  The  cough  ceased  during  sleep  but  began  at 
once  on  waking,  and  was  entirely  uncontrollable.  All  remedies  failed  to  relieve  him 
until  they  were  directed  to  the  nervous  system.  The  administration  of  valerianic  1 
acid  and  atropia  (evkjently  valerianate  of  atropia)  in  large  doses  caused  the  barking 
to  cease  almost  immediately.  In  this  case  Bosredon  applied  to  the  affection  the  term 
“ Choree  laryngienne,  ” although  he  at  the  same  time  considered  it  allied  to  the  affection 
termed  “ delire  des  aboyeurs,”  the  delirium  of  the  barkers,  which  was  first  observed 
in  the  sixteenth  century  by  Wiesus,  among  several  of  the  religious  enthusiasts  in  the 
Convent  of  Sainte  Brigette,  and  later  in  the  large  number  of  barking  women  near  Dox, 
in  1613,  and  in  the  “ Mewing  Orphans  ” at  Amsterdam. 

During  the  past  ten  years  cases  have  been  reported  by  Wheeler,2  Langmaid,3  Lef- 
ferts,4  Schrotter,5  Schreiber,6  Geissler,7  Massei,8  Revillout,9  Holland,10 11  Blanchez," 
Knight,12  Major,’3  Holden,  14 *  Keimer,’6  Ledbetter,  16  in  which  this  manifestation  in  the 
larynx  was  recognized  as  a distinct  affection. 

The  following  four  cases  of  this  affection  have  commanded  my  observation: — 

Case  i.— Miss  S , age  seventeen,  was  brought  to  me  in  May,  1885, -on  account 

of  a cough  of  a peculiar  barking  character,  which  she  had  had  about  two  months.  She 
was  of  a somewhat  delicate  constitution  and  nervous  temperament,  but  had  always  • 
enjoyed  very  good  health.  The  cough  followed  au  attack  of  quinsy,  the  result  of  expo- 
sure from  wet  feet.  She  recovered  promptly  from  the  quinsy,  but  soon  after  was  sud- 


1 Jour,  de  Med.  de  Bordeaux,  1S57,  2d  series,  p.  208. 

3 Boston  Med.  and  S.  Jour.,  1878,  Yol.  xcix,  page  503.  3 Id.,  page  505. 

4 Transactions,  Am.  Laryng.  Assn.,  1S79,  page  234. 

6 Ally.  Wien.  Med.  Zlg.,  1879,  xxiv,  page  67. 

0 Wien.  Med.  Bldt.,  1879,  II,  350. 

7 Jahresb.  d.  Oescllsch.  f.  Nat.  u.  Heilkunde  in  Dresden,  Leipzig,  1879,  63. 

s “Gior  internaz.  d.  So.  Med.,”  Napoli,  1S79,  i,  662. 

9 Gaz.  d Hop.,  Paris,  1880,  uil,  746. 

10  Louisville  Med.  News,  1881,  XI,  232. 

11  Gaz.  held,  de  Med.,  Paris,  1883,  2 S.  xx,  692. 

13  Transactions  Am.  Laryng.  Assn.,  18S3,  pago  23. 

13  Canada  Med.  & Surg.  Journ.,  Montreal,  1885-6,  xiv,  337. 

14  New  York  Med.  Jour.,  1S85,  XLI,  37. 

10  Deutscli.  Med.  Wochenschr.,  No.  40,  687. 

10  Alabama  Med.  & Surg.  Jour.,  Birmingham,  1886,  i,  3S7. 


SECTION  XIII — LARYNGOLOGY. 


83 


denly  seized  with  an  uncontrollable  cough  of  extreme  violence  and  of  a loud  barking 
,1  character,  much  resembling  the  peculiar  shrill  bark  of  some  dogs.  It  was  so  loud  that 
it  could  be  heard  one-quarter  of  a mile,  and  excited  so  much  curiosity  that  boys  would 
congregate  near  by  to  hear  the  girl  bark.  She  would  cough  thirty  or  forty  times  in 
rapid  succession,  then  there  would  be  a rest  for  about  one  minute  and  then  a repetition 
of  the  paroxysm.  The  cough  ceased  entirely  at  night  during  sleep,  which  was  natural 
and  calm.  If  she  slept  during  the  day  the  cough  would  also  cease,  but  would  return 
instantly  upon  waking. 

On  laryngoscopic  examination  the  larynx  was  found  congested,  particularly  about 
the  vocal  cords  and  posterior  commissure,  which  condition  was  attributed  to  the  vio- 
lent concussion  of  the  cords.  Between  the  intervals  of  coughing  there  was  a restless- 
ness of  the  larynx  and  a peculiar  twitching  of  the  cords,  which  increased  until  the 
next  paroxysm.  Various  local  applications  were  made  to  the  larynx  in  the  form  of 
sprays  of  astringent,  anodyne  or  sedative  character.  Internally,  bromides  in  large  doses 
and  sedative  cough  mixtures  were  given.  Galvanism  was  used,  but,  also,  without 
; apparent  benefit.  The  only  way  in  which  the  cough  could  be  controlled  was  by  the  hypo- 
; dermic  injection  of  morphia  and  atropia  over  the  inferior  laryngeal  nerves,  and  this 
• only  arrested  the  cough  while  the  effect  of  the  drugs  continued.  She  was  seen  by  a 
: large  number  of  physicians,  and  was  given  a great  variety  of  medicines,  but  without 
apparent  benefit,  and  the  cough,  which  commenced  in  March,  gradually  increased  in 
intensity  and  continued  uninterruptedly  until  October,  when  it  ceased  as  suddenly  as 
it  came.  The  patient  has  had  no  manifestation  of  the  trouble  since. 

The  diagnosis  was  generally  concurred  in  that  it  was  hysteria,  although  there  was 
no  other  evidence  of  that  affection,  as  her  menstruation  was  perfectly  regular  and  there 
- was  no  evidence  of  any  uterine  derangements.  At  the  time  I was  unable  to  classify 
the  affection,  but  subsequent  study  of  such  cases  has  convinced  me  that  it  was  clearly  a 

(case  of  chorea  of  the  larynx. 

Case  ii. — A robust,  well-developed  girl,  thirteen  years  old,  living  in  Brockport, 
N.  Y.,  was  referred  to  me  on  account  of  a peculiar  barking  cough  which  she  had  had  for 
■ about  two  months.  This  cough  came  on  without  assignable  cause  and  was  gradually 
t increasing  in  severity.  The  cough  was  quite  loud  and  resembled  that  of  a small  poodle 
i dog.  She  would  cough  fifteen  or  twenty  times  in  rapid  succession,  when  there  would 
be  a rest  for  two  or  three  minutes  and  then  a repetition  of  the  paroxysm.  On  laryn- 
•<  goscopic  examination  the  arytenoid  cartilages  and  ary-epiglottic  folds  were  found 
markedly  congested,  but  between  the  paroxysms  of  cough  the  larynx  remained  eom- 
1 paratively  quiet,  and  little  or  no  twitching  and  restlessness  found  in  the  former  case  was 
i manifest,  except  just  before  and  during  the  paroxysm  of  coughing.  Physical  examina- 
i tion  of  the  chest  revealed  emphysema  of  the  middle  lobe  of  the  right  lung,  which  was 
d evidently  caused  by  the  expiratory  pressure.  Local  applications  wTere  made  to  the 
larynx  of  a solution  of  sulpho-carbolate  of  zinc  and  tincture  iodine  on  cotton.  Gal- 
1 vanism  was  applied  to  the  larynx  externally  and  a hydrocyanic  acid  and  morphia  cough 
- mixture  was  given.  The  cough  at  once  began  to  subside,  and  in  about  five  days  the 
< barking  character  of  the  cough  entirely  disappeared.  The  treatment  to  the  larynx  was 
i continued  a short  time  longer  until  all  the  local  trouble  in  the  larynx  had  disappeared. 

' A member  of  her  family,  a short  time  ago,  told  me  that  she  had  remained  entirely 
'.  well  since. 

The  cough  in  this  case  was  at  first  ascribed  to  enlarged  tonsils.  These  were  excised 
before  I saw  her,  and  when  no  benefit  to  the  cough  resulted  it  was  ascribed  to  hysteria, 

‘ although  she  did  not  have  a nervous  temperament ; and,  as  in  the  first  case,  there  was 
i no  other  suspicion  of  such  influence,  except  that  it  slightly  preceded  her  first  menstrua- 
tion. 

Case  hi. — A boy,  seventeen  years  old,  of  a highly  nervous  temperament,  who  had 


84 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


had  general  good  health,  was,  two  months  before  I saw  him,  attacked  with  a violent 
cough  of  a peculiar,  shrill,  short,  barking  character.  This  cough  followed  an  attack  of 
sore  throat  (a  pharyngitis  or  acute  catarrhal  tonsillitis),  the  result  of  cold  from  wet 
feet.  The  cough  was  at  first  moderate  in  intensity,  but  gradually  increased  both  in 
severity  and  frequency  until,  at  the  time  I saw  him,  he  would  cough  ten  or  fifteen 
times  in  rapid  succession,  and  after  an  interval  of  two  or  three  minutes  the  attack  would 
be  repeated.  This  would  continue  without  interruption,  even  at  meals,  and  also  to 
some  extent  during  sleep  without  awakening  the  patient. 

On  examination  there  was  a well-marked  congestion  of  the  whole  larynx,  but  more 
pronounced  over  the  arytenoid  cartilages.  The  vocal  bands  were  reddened  along  the 
inner  border,  where  they  came  in  collision  with  each  other  during  the  laryngeal  spasm. 
The  action  of  the  larynx  during  the  act  of  coughing,  as  observed  in  the  laryngeal  mir- 
ror, was  as  follows  : — 

Immediately  following  each  act  of  coughing  there  was  a momentary  rest,  then  an 
incoherent  action  and  twitching  of  the  larynx.  The  cords  were  then  violently  approx- 
imated and  held  there  for  an  instant,  when  they  were  abruptly  forced  apart  and  the 
cough  took  place. 

The  diagnosis  of  this  case  as  laryngeal  chorea  should  not,  it  seemed,  be  questioned, 
although  this  condition  of  the  larynx  and  the  cough  were  the  only  manifestations  of  a 
choreic  condition.  There  was  also  a so-called  neurotic  condition  in  the  family.  The 
mother  was  hysterical,  an  older  sister  had  had  general  chorea  when  nine  years  old,  hut 
recovered  from  it,  and  the  person  under  treatment  had  had  convulsions  during  his  first 
dentition. 

In  the  treatment  of  this  case,  local  applications  to  the  larynx  of  astringent  and  ano- 
dyne preparations  would  arrest  the  paroxysms  at  once  and  as  long  as  the  effect  of  the 
remedies  continued.  Application  of  cocaine  to  the  larynx  afforded  no  relief,  but,  on 
the  contrary,  increased  the  laryngeal  distress.  He  was  also  placed  on  of  a grain 
of  arsenious  acid  every  four  hours;  valerianate  of  zinc  and  dyalised  iron  were  also  given. 
Under  this  combined  plan  of  treatment,  together  with  galvanism  of  the  pneumogastric 
nerve,  he  gradually  improved  in  strength,  the  cough  slowly  subsided,  and  at  the  end  of 
six  weeks  had  entirely  disappeared.  A year  and  a half  has  elapsed,  with  no  evidence 
of  a recurrence  of  the  affection. 

Case  iv. — Miss  M.,  aged  sixteen,  of  Hornellsville,  N.  Y.,  was  referred  to  me  by  her 
family  physician,  May  25th,  1887,  on  account  of  a distressing  cough  which  she  had  had 
for  about  three  months.  During  the  latter  part  of  last  February  she  took  a severe 
cold,  mainly  in  her  head,  and  two  or  three  days  afterward  she  began  to  have  this  peculiar 
cough.  She  would  cough  from  four  to  ten  times  in  rapid  succession,  then  there  would 
be  a respite  of  from  three  to  five  minutes,  when  the  paroxysm  would  be  repeated.  The 
cough  was  loud  but  deep-toned,  a combination  of  a bark  and  a bellow,  resembling 
somewhat  the  bark  or  bellow  of  a sea-lion.  In  the  intervals  between  the  paroxysms 
she  would,  in  addition,  often  cough  a natural  cough  of  a short,  irritable  nature — an 
ordinary  cough  from  laryngeal  irritation.  Sometimes  these  two  coughs  would  alternate, 
or  occasionally  the  natural  cough  would  take  the  place  of  the  bark.  During  each 
paroxysm  of  coughing  there  would  be  a marked  swelling  in  the  left  front  part  of  the 
neck,  which  she  would  instinctively  grasp  with  her  right  hand  to  prevent  its  hurting 
her.  Three  years  before  she  had  had  a similar  cough,  following  a cold,  although  not  so 
loud  or  deep  toned,  which  was  promptly  cured  by  applications  made  to  the  pharynx. 
The  same  treatment  had  been  persistently  pursued  this  time,  by  the  same  physician,  but 
without  the  slightest  benefit.  Bromide  of  potassium  and  other  nerve  sedatives  had  also 
been  given  in  large  doses,  but  without  effect  on  the  cough. 

Her  general  health  had  always  been  delicate.  Eight  years  ago  she  had  scarlet  fever, 
with  an  abscess  in  the  left  ear.  A perforation  of  the  membraua  tympaui  resulted,  and 


SECTION  XIII — LARYNGOLOGY. 


85 


there  has  been  more  or  less  discharge  from  that  ear  since.  Daring  the  past  three  years  she 
has  had  much  pai n j ust  back  of  the  eyes,  which  glasses  had  failed  to  relieve.  She  has 
now  amaurosis  in  the  left  eye,  with  almost  complete  loss  of  sight  in  that  eye. 

The  cough  in  this  case  was  so  particularly  distressing  to  hear,  that  it  was  with  great 
difficulty  she  could  lind  a boarding-place  while  under  treatment.  At  hotels  she  attracted 
so  much  attention  that  she  would  not  remain,  and  at  private  boarding  houses  they  were 
not  willing  to  entertain  her. 

As  in  the  preceding  case,  cocaine  applied  to  the  throat  and  larynx  not  only  did  not 
check  the  cough,  but  actually  increased  it,  and  caused  a distressed  feeling  in  the  larynx, 
due,  undoubtedly,  to  its  contracting  effect.  The  cough  did  not  cease  at  night  during 
sleep,  but  would  continue  all  night  without  awakening  her.  She  experienced  no  pain 
about  her  throat  at  any  time,  only  this  sensation  of  pressure  from  the  swelling  which 
: took  place  each  time  that  she  coughed.  There  was  no  evidence  of  any  uterine  trouble, 
and  her  menstruation  had  always  been  regular. 

On  examination,  the  larynx  appeared  pale  and  anaemic,  although  the  vessels  were 
; distended,  giving  the  larynx  a streaked  appearance.  The  mucous  membrane  had  a 
pale,  puffy  appearance,  particularly  over  the  arytenoid  cartilages  and  along  the  ventri- 
cular bands.  After  each  paroxysm  the  larynx  would  remain  for  a short  time  perfectly 
'■  |uiet,  excepting  the  respiratory  movements  ; but  before  the  onset  of  the  paroxysm,  the 
< action  of  the  larynx  would  become  restless,  the  arytenoid  and  vocal  cords  would  begin 
to  twitch  and  then  come  into  violent  contact,  when  an  explosive  separation  would  take 
place  and  the  cough  follow.  The  swelling  of  the  neck  I at  first  thought  to  be  a tracheal 
i hernia  or  tracheocele,  but  it  would  only  occur  during  the  peculiar  cough,  and  as  she 
i could  not  produce  it  at  will  by  holding  her  breath  during  a forcible  expiration,  or  during 

■ the  ordinary  cough,  it  was  evidently  due  to  the  forcible  contraction  of  the  thyro-hyoid 
muscles.  Pressure  over  the  cricoid  cartilage  externally  would  at  once  start  the  bark- 
ing, and  keep  it  going  so  long  as  the  pressure  was  applied.  Application  of  the  Faradic 
current  to  the  neck  would  also  aggravate  the  cough. 

The  treatment  of  this  case  was  both  local  and  general,  and  resulted  in  complete  relief, 
: although  the  ordinary  slight  laryngeal  cough  persisted  to  some  extent.  Since  the  cessa- 
tion of  this  peculiar  bark  she  cannot  reproduce  or  even  imitate  it.  The  treatment  con- 
sisted in  the  application  to  the  interior  of  the  larynx,  on  cotton,  of  a solution  of  sulpho- 
» carbolate  of  zinc,  extract  of  krameria  and  eucalyptus.  This  was  also  applied  to  the 
fauces.  Internally,  arsenic  and  iron  and  bark. 

It  is  a curious  fact  to  note  that  the  first  application  of  the  preparation  to  the  interior 
1 of  the  larynx  arrested  the  peculiar  cough  for  three  or  four  hours,  or  during  the  con- 
tinuance of  the  effect  of  the  remedy,  while  the  application  of  ten  per  cent,  solution  of 
c,  cocaine  aggravated  rather  than  decreased  it.  To  me,  the  only  satisfactory  explanation 
1 of  this  is  the  following  : While  the  cocaine  benumbed  the  terminal  filaments  of  the 
nerves  in  the  larynx,  where  nearly  all  the  primary  disease  was  located  (as  shown  in  the 
1 arrest  of  the  cough  by  the  local  medication  which  had  no  anodyne  effect  whatever),  the 
contraction  of  the  tissues  caused  by  the  cocaine  exerted  a pressure  on  the  deeper  por- 

■ tions  of  the  recurrent  nerve  which  had  become  sensitive,  and  thus  produced  an  irrita- 
tion which  was  reflected  to  the  nerve  centres. 

An  interesting  and  peculiar  symptom  in  these  last  two  cases  was  the  continuance  of 
; so  violent  a bark  during  sleep,  without  wakening  the  patients.  I have  found  no  other 
peases  reported  in  which  this  symptom  was  present.  Its  cause  was  certainly  the  same  as 


i that  of  the  day  bark,  for  they  corresponded  to  each  other  and  both  ceased  together. 

Regarding  the  pathology  of  chorea,  a different  view  is  held  by  nearly  every  writer 
i on  the  subject.  Thus,  Hughlings-Jackson  tells  us  that  it  is  due  to  capillary  emboli  in 
i the  corpus  striatum  and  optic  thalamus.  Dickenson  tells  us  that  it  is  due  to  a general 

I dilatation  of  the  smaller  arterial  vessels  throughout  the  substance  of  the  brain  and  cord, 

* 


86 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


attended  with  exudation  into  the  surrounding  tissues.  Legros  and  Oninius  tell  us  that 
the  site  of  chorea  is  either  iu  the  nerve  cells  of  the  posterior  horns,  or  in  the  fibres 
which  connect  them  with  the  motor  cells.  While  Brown- Sequard  ascribes  it  to  a 
“softening  of  the  cord.” 

The  diversity  of  opinion  held  by  the  few  authorities  that  I have  cited  regarding  the 
pathology  of  this  affection,  simply  reflects  the  lack  of  definite  knowledge  concerning  it. 
Therefore,  in  the  absence  of  a known  positive  pathology,  we  must  rely  wholly  on  its 
symptomatic  manifestations. 

It  is  true,  as  Massei  says,  laryngeal  chorea  describes  a manifestation  and  not  a dis- 
ease. But  such  is  the  case  with  chorea  in  every  form,  and  also  with  many  other  affec- 
tions ; aud  it  should  not  for  this  reason  go  unnamed  until  we  can  establish  for  it  a posi- 
tive pathology.  If  the  term  is  without  pathological  significance,  it  cannot  be  less  satis- 
factory than  hysteria,  which  is  the  ‘ ‘ diagnostic  refuge  ’ ’ for  all  forms  of  uncertain  mani- 
festations of  a neurotic  character.  As  Knight1  and  Major2  remark,  whenever  the 
movements  of  the  larynx  are  choreic  we  are  justified  in  using  the  term;  the  evidence 
of  a general  chorea  should  confirm  and  fortify  rather  than  weaken  or  detract  from  the 
diagnosis.  That  there  is  not  necessarily  a direct  connection  between  choreic  symptoms 
of  local  origin  and  a general  neurosis  is  becoming  more  and  more  generally  recognized. 

The  local  origin  of  many  choreas  is  very  clearly  pointed  out  in  the  recent  article  by 
Jacobi.3  In  alluding  to  the  frequency  of  convulsive  movements  of  the  face  and  upper 
portion  of  the  trunk  due  to  irritation  in  the  naso-pharyngeal  region,  he  says  : “If  gen- 
eral nervousness  were  the  cause,  its  effects  would  be  apt  to  be  general.  For  the  local 
effect,  there  is  a local  cause  ; even  in  the  usual  form  of  generalized  chorea  the  involun- 
tary, spasmodic,  reflex  movements  are  occasioned  by  local  irritation.” 

Krishaber4  calls  attention  to  “vocal  asynergy,”  a term  which  is  used  to  imply  a 
want  of  command  over  the  laryngeal  muscles,  generally  occurring  during  some  form  of 
laryngitis,  but  sometimes  arising  idiopathically. 

Yon  Ziemssen  5 describes  a condition  of  the  laryngeal  muscles  accompanying  general 
chorea,  in  which  there  is  a restlessness  and  twitching  contraction  of  the  closers  and 
openers  and  tensors  of  the  vocal  cords.  “ It  is  characterized,”  he  says,  “by  insufficient 
force  and  duration  of  the  tension  of  the  vocal  cords  in  phonation,  owing  to  a want  of 
coordination  and  persistence  in  the  muscular  act.” 

Our  eminent  London  friend,  Mr.  Lennox  Browne,  who  is  present,  states,  in  the  last 
edition  of  his  excellent  work, 6 which  has  just  been  issued,  and  which  I had  the  pleasure, 
by  his  kindness,  of  perusing  last  evening,  that  this  form  of  neurosis  of  the  larynx  occurs 
in  the  course  of  a general  chorea.  He  also  states  that  “Inasmuch  as  it  represents 
fatigue  and  spasm  of  one  set  of  muscles,  through  wrong  use  and  over-use  of  another, 
this  4 psellismus  laryngis  ’ bears  some  analogy  to  the  conditions  comprised  under  the 
designation  of  ‘ writer’s  cramp.’  ” 

The  neurotic  character  of  many  coughs  due  to  irritation  in  the  larynx,  reflected  from 
disease  in  the  nasal  passage,  is  very  frequently  observed  by  laryngologists.  Not  only' 
do  we  first  look  for  a local  cause  iu  all  forms  of  localized  choreic  manifestations,  but  we 
often  find,  on  careful  examination,  a general  chorea,  due  to  a localized  cause.  Thus, 
M.  Boretti 7 reports  the  case  of  a boy,  thirteen  years  old,  who  had  had  a violent  chorea 


1 Op.  Cit.  3 Op.  Cit.,  page  338. 

3 “ Partial,  and  sometimes  general,  chorea  minor  from  naso-pharyngeal  reflex.”  American 

Journal  Medical  Science »,  Vol.  XCI,  1886,  page  517. 

1 “Diet,  do  Sc.  Med.,”  page  681.  Mackenzie,  “ Dis.  of  the  Throat  and  Nose.”  London,  1880. 

Vol.  i,  page  495.  8 “ Cyclopasd.  Prac.  Med.,”  Vol.  xiv,  page  436. 

• “ The  Throat  and  its  Diseases.”  London,  1887,  page  480. 

7 Bulletin  de  la  Sociiti  dc  Chirunj.,  1852,  page  252. 


SECTION  XIII — LARYNGOLOGY. 


87 


for  thirteen  months  that  had  resisted  all  forms  of  treatment.  On  the  removal  of  a neu- 
romatous tumor  that  was  discovered  on  the  bottom  of  one  of  his  feet,  the  choreic  symp- 
toms immediately  disappeared. 

A case  is  reported  hy  Fischer1  of  unilateral  chorea  caused  by  the  stump  of  a tooth. 
On  removal  of  the  roots  of  the  tooth,  the  choreic  movements  entirely  disappeared. 

As  local  choreas  are  most  often  the  manifestation  of  an  irritation  of  some  portion  of 
i the  nerve  which  supplies  that  region,  we  would  therefore  expect  to  find  in  chorea  of  the 
: ■ larynx  an  abnormal  excitation  of  the  pneumogastric  nerve  or  some  of  its  branches.  This 
was  unquestionably  the  case  in  three  of  the  cases  that  I have  reported,  and  confined 
almost  entirely  to  the  nerves  supplying  the  larynx.  In  the  other  patieut  the  cause  was 
doubtless  central  or  due  to  the  irritation  of  the  nerve  centre  from  which  the  pneumo- 
gastric is  derived. 

The  diagnosis  of  chorea  laryngis  can  only  he  made  by  a laryngoscopic  examination. 
The  peculiar  cough  usually  attending  this  affection  is  not  significant.  In  nearly  all 
cases  of  laryngeal  chorea  the  respiratory  as  well  as  the  laryngeal  branches  of  the 
pneumogastric  are  involved,  giving  expression  in  peculiar  and  involuntary  coughs. 
Two  cases  have  been  reported  by  Knight2  in  which  the  choreic  movements  were 
l confined  entirely  to  the  larynx  and  unattended  by  cough. 

Hysteria  of  the  larynx  is  the  only  affection  with  which  chorea  laryngis  is  liable  to 
be  confounded.  The  characteristic  manifestations  of  hysteria  of  the  larynx  are  those 
of  aphonia,  spasm,  anaesthesia  and  hypersesthesia ; while  chorea  laryngis  is  characterized 
i only  hy  a peculiar  choreic,  incoherent  action  or  incoordination,  or,  as  Watson  would 
i term  it,  an  “insanity”  of  the  laryngeal  muscles.  It  may  not  be  impossible  for  a 
■'  laryngeal  chorea  to  he  of  an  hysterical  origin ; that  is,  due  to  an  irritation  reflected  from 
l the  uterus.  It  is  not  the  cause  or  direction  from  which  the  irritation  comes  that  is 
significant,  hut  it  is  the  peculiar  choreic  manifestations  of  the  larynx  that  are  diagnostic. 

From  a study  of  the  cases  that  I have  reported,  and  of  those  reported  by  others,  I 
am  led  to  the  following  conclusions 

1.  That  chorea  laryngis  is  a term  applicable  to  all  forms  of  movements  of  the  larynx 
' that  are  choreic. 

2.  That  this  phenomenon  may  he  excited  by  a local  disease  of  the  larynx,  or  hy 
a disease  of  the  central  nerve  centres.  In  the  former  it  is  of  a reflex  character,  involv- 
ing the  sympathetic  ; in  the  latter  it  is  direct,  involving  the  centres  from  which  the 
nerve  supply  to  the  larynx  is  derived. 

3.  That  anaemia  or  a depressed  condition  of  the  system  is  present  in  every  case, 
i favoring  in  one  instance  a ready  transmission  of  the  local  irritation  to  the  nerve  ganglia, 

I and  hack  again  to  the  larynx;  and  in  another  instance  a ready  transmission  of  the  irri- 
tation from  the  diseased  nerve  centres  to  the  periphery. 

J4.  That  choreic  conditions  of  the  larynx  are  usually  attended  with  spasmodic 
actions  of  the  respiratory  muscles,  manifested  in  a peculiar  bark  or  cough,  but  not 
necessarily  so,  for  two  cases  of  chorea  of  the  larynx  unattended  by  cough  have  been 
i reported. 

5.  That  in  some  cases  coughs  or  barks  choreic  in  character  are  hysterical.  In  these 
1 cases  they  are  attended  by  other  hysterical  symptoms  and  sometimes  spasms  of  the 
larynx,  but  there  is  an  absence  of  the  incoherent  actions  of  the  larynx  which  are  diag- 
nostic of  this  affection. 

6.  That  the  prognosis  in  these  cases  is  favorable.  In  some,  the  affection  ceases 
spontaneously. 


1 Zeitschrift  fur  Wund'drzte,  1853,  Bd.  v,  page  89. 

“Case  i,  Archives  of  Laryngology,  Vol.  i,  1879,  pago  254.  Case  II,  Transactions  American 
Laryngological  Ass.,  1883,  page  26. 


88 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


7.  That  in  the  treatment  of  this  affection,  when  the  exciting  cause  is  localized  in 
the  larynx,  as  it  was  in  three  of  the  cases  which  I have  reported,  the  larynx  must  of 
neccessity  receive  appropriate  treatment.  But  in  those  cases  where  the  disease  is  cen- 
tral, the  plan  to  be  pursued  is  that  which  should  govern  the  treatment  of  chorea  in 
general. 

DISCUSSION. 

Dr.  Max  Thorner,  of  Cincinnati,  0. , said  he  saw  two  cases  of  so-called  chorea 
laryngis,  where  the  chorea  was  one  of  the  frequent  nervous  complications  of  preg- 
nancy. The  first  was  that  of  a girl,  get.  15,  who  appeared  in  Prof.  Schnitzler’s 
clinic  in  Vienna,  with  a frequent,  barking  cough;  laryngoscopically  only  frequent 
adduction  and  abduction  of  the  vocal  cords  could  be  seen.  Gynaecological  examination 
showed  the  girl  to  be  in  the  fourth  month  of  pregnancy.  The  second  case  was  that 
of  a married  lady,  get  24.  She  consulted  me  for  a loud,  hacking  cough  in  the  seventh 
month  of  pregnancy.  No  signs  of  disease  in  the  larynx  could  be  detected,  except 
twitching  of  the  vocal  cords.  The  lady  was  of  exceedingly  nervous  temperament. 
The  cough  ceased  spontaneously  a short  time  before  the  delivery,  just  as  had  been 
the  case  in  her  first  pregnancy. 

Dr.  E.  Cutter,  of  New  York,  asked  Dr.  Roe  to  say  where  he  would  place  a case 
of  a voluntary  barking  cough  in  a young  lady  of  18  years,  which  she  could  cause  at 
will,  but  which  attracted  the  attention  of  all  observers.  On  laryngoscopy  the  larynx 
and  throat  were  found  normal,  save  that  both  false  or  ventricular  bands  were  thick- 
ened to  thrice  their  normal  size.  This  appeared  to  me  to  explain  the  cough,  especi- 
ally as  I found  a case  of  so-called  spasmodic  cough,  in  which  this  same  pathological 
condition  was  found.  The  Doctor  said  it  was  probably  not  chorea. 

Mr.  Lennox  Browne  had  seen  occasionally  cases  presenting  choreii  laryngeal 
symptoms  without  cough,  but  he  had  seen  many  of  nervous  laryngeal  cough.  They 
were  generally  of  a reflex  nature,  and  when  the  cause  of  the  reflex  was  not  readily 
ascertainable,  the  benefit  of  a sea  voyage  was  very  marked  and  generally  permanent. 

Dr.  Roe,  in  closing  the  discussion,  said — The  last  speaker,  Dr.  Ingals,  has  called 
attention  to  the  special  diagnostic  feature  of  this  affection,  which  I emphasized  in 
my  paper,  but  which  the  other  speakers  have  overlooked  in  their  remarks,  namely, 
the  peculiar  and  characteristic  incoherent  action  or  choreic  condition  of  the  laryngeal 
muscles,  which  can  only  be  diagnosticated  by  the  aid  of  the  laryngeal  mirror. 

We  also  have  very  frequently  reflex  coughs  of  a peculiar  character  caused  by 
irritation  in  the  nose,  pharynx,  larynx,  or  the  fauces,  as  in  the  cases  of  cough  excited 
by  enlarged  tonsils,  cited  by  Mr.  Browne.  Such  cases,  however,  are  not  cases  of 
chorea  laryngis,  unless  the  larynx  presents  the  peculiar  and  characteristic  choreic 
manifestations. 

The  peculiar  coughs,  moreover,  that  frequently  attend  pregnancy,  of  which  Mr. 
Browne  and  Dr.  Thorner  have  spoken,  are  doubtless  due  to  irritation  reflected  from 
the  enlarged  uterus  to  the  pneumogastric  nerve,  as  evinced  by  the  cessation  of  the 
cough  after  parturition.  It  is  not  impossible  that  there  may  be  in  some  of  these 
cases  temporary  chorea  of  the  respiratory  and  laryngeal  muscles,  but  in  the  absence 
of  a laryngoscopic  examination  we  are  not  warranted  in  classifying  any  such  coughs 
as  chorea  laryngis. 


SECTION  XIII — LARYNGOLOGY. 


89 


Dr.  Max.  J.  Stern,  of  Philadelphia,  read  a paper  entitled — 

INTUBATION  OR  TRACHEOTOMY. * 

INTUBATION  OU  TRACIIEOTOMIE. 

INTUBATION  ODER  TR A CHEOTOMI E. 

BY  DR.  MAX.  J.  STERN, 

Of  Philadelphia,  Pa. 

The  following  paper  considers  tracheotomy  and  intubation  only  in  their  relation  to 
liphtheria  and  croup  ; for  intubation  lias  as  yet  been  so  rarely  practiced  for  the  relief 

! if  other  affections,  that  it  would  be  unjust  to  draw  any  comparisons  between  the  two 
procedures,  in  any  other  than  the  diseases  named.  Until  within  a recent  period,  there 
was  but  one  method  which  could  be  employed  for  the  prolongation  of  life  when 
isphyxia  confronted  us.  It  remained  for  Dr.  O’ Dwyer  to  place  in  our  hands  an  instru- 
ment, the  importance  of  which,  in  a little  more  than  two  years,  already  rivals  that 
method  for  the  promulgation  of  which  Bretonneau,  Trousseau,  and  many  others  have 
50  faithfully  labored. 

When  but  oue  line  of  conduct  can  be  employed  for  the  relief  of  a particular  affection, 
there  ought  to  be  no  doubt  as  to  the  manner  of  interference.  With  two  methods,  where 
the  position  of  one  is  not  yet  determined,  the  particular  applicability  of  the  one  or  the 
other  is  the  point  upon  which  elucidation  is  needed.  My  earnest  hope,  therefore,  is 
that  in  the  discussion  which  may  ensue  some  light  may  be  thrown  upon  this  particular 
point. 

Tracheotomy  was  proposed  for  the  relief  of  serious  cases  of  angina  in  remote  anti- 
quity ; Ccelius  Aurelianus  and  Galen  accrediting  Asclepiades  with  it,  in  the  time  of 
Cicero.  Autyllus  is  the  first  who  described  a manner  of  operating,  and  is  cited  by 
Paulus  oEgineta.  Fabricius  ab  Acquapendente  advised  the  use  of  a cannula  with  wings. 

: Casscrio  argued  in  favor  of  the  operation,  and  gave  a complete  description  of  it.  Rhazes, 
Mesue  and  Avicenna  spoke  of  bronchotomy  as  a supreme  resource  in  suffocative  tonsil- 
litis. Avenzoar  performed  tracheotomy  successfully  on  a goat.  The  operation  then 
fell  into  disuse  until,  in  1546,  Antonio  Musa  Brassavalo,  physician  to  the  Duke  of  Fer- 
rara, performed  a successful  one  for  suffocative  angina.  Laryngocentesis  was  first  per- 
formed by  Santonio,  about  1600,  and  again  by  Garengeot,  in  1748.  In  1730  Dr.  George 
Martine  (27)  performed  the  first  successful  and  recorded  tracheotomy  for  croup,  but 
cited  earlier  successes  by  Mr.  Baxter  and  Dr.  Oliphant.  About  1750  Heister  recom- 
mended a mode  of  operating  similar  to  that  now  practiced.  Decker,  Boucliut,  Barbeau- 
Dubourg  and  Richter  invented  special  bronchotomes.  Tracheotomy  was  also  recom- 
mended by  Habicot,  Severinus,  Rene  Moreau  and  DeVeiga.  Home,  about  1765,  recom- 
mended it  as  a dernier  ressort  in  croup.  D’Azyr,  in  1776,  published  a work  on  Laryn- 
gotomy.  Stoll,  in  1736, 1 strongly  advocated  the  operation,  although  he  had  never  seen 
it. 

The  next  credited  success  was  that  of  John  Andre,  in  London,  in  1782,  and  recorded 
by  Borsieri.2  This  was  followed  by  Thos.  Chevalier,3  of  London,  in  1814,  and  Breton- 
■ neau  after  two,  and  according  to  Guersant  six,  unsuccessful  operations,  achieved  his 
j first,  and  the  fourth  recorded,  success,  in  1825.  After  the  report  of  M.  Royer-Collard 
on  the  Concours  of  1807, 4 the  Academie  de  Medecine  strenuously  opposed  tracheotomy. 
This  was  evidently  to  check  the  enthusiasm  of  Caron,  who  was  its  staunchest  advocate, 


* References  an<l  bibliography  will  bo  found  at  end  of  the  paper. 


90 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


and  who  offered  a prize  of  one  thousand  francs  to  any  one  who  would  cure  a case  of 
croup  by  opening  the  windpipe. 

It  was  Bretonneau’s  task  to  demonstrate  the  feasibility  of  the  operation  to  the 
French.  He  and  his  student  Trousseau  remained  its  strongest  exponents  throughout 
their  lives,  and  it  is  due  mainly  to  the  efforts  of  these  men  that  the  operation  was  per- 
fected. Bretonneau6  in  his  first  operation  used  a goose  quill  for  the  passageway  of  air 
to  the  lungs,  in  the  second  a piece  of  wax  catheter,  in  the  third  a curved  silver 
cannula,  which,  for  practical  purposes,  is  almost  identical  with  the  single  tubes  until 
recently  in  use. 

After  Bretonneau’s  success  the  operation  steadily  gained  in  favor,  and  in  1835  Trous- 
seau6 reported  sixty  cases  of  tracheotomy  for  croup,  with  eighteen  authenticated  recov- 
eries. They  were  divided  among  the  following  operators  : — 


Bretonneau 17  operations  and  5 recoveries. 

Trousseau 36  “ “ 9 “ 

Scouttetten 1 “ “1  “ 

Senu,  of  Genova 1 “ “ 1 “ 

Gerdy 1 “ “ 1 “ 

Andre 1 “ “1  “ 

Velpeau 1 “ “ Failure. 

Guersant,  Jr 1 “ “ “ 

Sanson,  the  elder 1 “ “ “ 

Blandin 1 “ “ “ 


It  will  thus  be  seen  that  thirty  per  cent,  of  the  earlier  cases  were  saved.  After 
1835  the  operation  became  general,  and  the  reported  cases  rapidly  multiplied,  and  it 
was  not  long  ere  the  operation  was  performed  in  all  parts  of  the  world. 

It  is  almost  impossible  to  gather  any  reliable  statistics  in  the  earlier  years  of  the 
operation,  as  there  is  so  much  difference  in  the  reports  of  various  authors,  who  yet 
seem  to  have  gained  their  information  at  the  same  sources.  The  most  trustworthy 
which  I have  been  able  to  find  are  those  given  in  Cohen’s  book  on  “Croup  and  its 
Relation  to  Tracheotomy.”  He  has  discarded  all  those  looked  upon  as  being  doubtful. 

It  is  from  this  magnificent  work  that  I have  in  part  taken  the  statistics  which  I shall 
shortly  give.  Many  excellent  works  have  recently  been  brought  forward,  but  none 
that  materially  change  the  ultimate  ratio  of  successes.  It  would,  indeed,  seem  that 
with  all  our  approved  appliances  the  total  percentage  of  recoveries  has  not  increased, 
although  occasionally  we  find  single  reports  where  fifty  per  cent,  of  recoveries  will  be 
noted,  which  is  over  twenty  per  cent,  more  than  the  gross  relation.  It  would  be  unjust 
to  take  any  single  group  of  statistics,  and  we  must  deduce  results  from  the  experience  of 
the  world. 

Tracheotomy  in  the  United  States,  until  recently,  has  not  given  very  encouraging 
results;  indeed,  in  certain  parts  of  the  country,  the  mortality  has  been  so  high  that  the 
mass  of  the  profession  refuse  to  sanction  the  operation,  and  it  is  often  as  difficult  to 
gain  the  consent  of  the  attendant  as  that  of  the  parents.  -9 

The  feasibility  of  tubage  of  the  larynx  was  accidentally  demonstrated  in  1801,  by 
Desault,  who  passed  an  oesophageal  catheter  into  the  trachea,  where  it  remained  for  some 
hours  without  causing  inconvenience,  but  the  patient  succumbed  when  the  bronchi  were 
filled  with  food  intended  for  the  stomach.  Bichat,  profiting  by  this  lesson,  placed  a 
catheter  in  the  larynx  of  a patient  suffering  from  acute  oedema  of  the  glottis.  It 
remained  in  situ  for  twenty-four  hours,  the  patient  recovering.  Green,  Chapman  and 
Loiseau  recommended  a like  procedure.  In  1835  Guersant 7 reported  Dupuytreu’s 
method  of  cleansing  the  trachea  in  croup  by  means  of  a small  sponge  attached  to  a 
whalebone  probang,  which  the  latter  had  first  practiced  on  a child  of  Bonaparte’s 
Mameluke.  Dieffenbach  employed  the  same  method  as  early  as  1839.  In  1854  Horace 
Green  injected  tuberculous  cavities  (?)  by  means  of  a flexible  tube  passed  into  either 


1 


SECTION  XIII — LARYNGOLOGY. 


91 


bronchus.  Iu  u case  of  oedema  of  the  glottis,  Hack  used  a Sehroetter  bougie  for  intu- 
batiug  the  larynx.  Monti,  of  Vienna,  has  for  a long  time  employed  a hard  rubber  tube, 
one  end  passing  into  the  larynx,  the  other  protruding  from  the  mouth,  as  a temporary 
substitute  for  tracheotomy.  McEwen  has  employed  catheters  passed  through  the  mouth 
to  relieve  dyspnoea.  Reichert,  Landgraf,  Weinlechner  and  others  hgve  resorted  to 
the  same  expedient. 

Intubation  of  the  larynx,  as  we  now  understand  it,  was  first  practiced  for  the  relief 
of  croup  by  Bouchut  iu  1857,  and  he  reported  in  1858,  to  the  Academie  de  Medecine  of 
Paris,  seven  cases  thus  treated,  two  of  which  recovered  after  subsequent  tracheotomy. 
Although  the  ultimate  result  was  bad,  he  claimed  an  immediate  relief  of  the  distressing 
dyspnoea. 

Through  the  efforts  of  Trousseau,  one  of  the  commission  appointed  to  investigate  its 
merits,  the  procedure  was  ridiculed  and  condemned,  and  in  consequence  fell  into  oblivion. 
It  should  be  borne  in  mind,  at  this  time  Trousseau  was  tracheotomy’s  staunchest 
champion. 

In  1880  Dr.  Jos.  O’Dwyer,  of  New  York,  ignorant  of  former  efforts,  began  experi- 
mentation iu  the  footsteps  of  Bouchut,  and  in  1885  published  the  results  of  his  labors. 
His  method  is  that  of  his  predecessor,  his  instruments  radically  different,  and  are  now 
so  familiar  that  they  need  no  description. 

Bretonneau  said,  “a  large  increase  in  the  fatality  of  tracheotomy  must  be  set  to  the 
negligence  or  ignorance  of  surgeons  who  imagine  with  the  performance  of  the  operation 
all  has  been  done  that  is  required.”  I know  from  my  own  experience  that  this  can  be 
applied  to  intubation,  the  operator  not  having  had  the  wit  to  discern  that  he  had  but 
eliminated  one  factor  to  be  combated  in  these  dread  diseases.  While  this,  of  course,  is 
applicable  to  but  few,  it  nevertheless  lowers  the  ratio  of  success. 

The  reports  various  operators  have  recently  published  in  reference  to  intubation 
have  sufficed  to  enable  me  to  present  a reasonable  number  of  cases,  which  we  will  pro- 
ceed to  dissect  and  compare  with  the  results  of  tracheotomy.  I will  omit  references,  but 
they  are  appended  to  the  paper  and  will  be  published. 

The  number  of  tracheotomies  derived  from  French  sources  were  in  part  gleaned 
from  Cohen’s  “Croup”8  and  in  part  from  Sanne’s  “Diphtheria,”9  the  latter  having 
personally  examined  the  hospital  registers.  We  can  then  gather  from  France  5151  trache- 
otomies ; of  these  there  were  1306  recoveries,  or  a ratio  of  24/^  per  cent.  From  Por- 
tuguese sources  10  we  get  59  operations  with  21  recoveries,  or  35x5ff  per  cent.  From 
Belgium,11  reported  by  Henriet  and  Warlomont,  we  have  43  cases  and  12  recoveries, 
or  27x%  per  cent.  From  Germanic12  sources  we  gather  1837  cases  showing  558  recov- 
eries, or  30r45  per  cent.  In  Switzerland  Dr.  D’Espine13  reports  148  operations  and 
57  recoveries,  or  38 per  cent.  From  England  14  we  can  obtain  333  tracheotomies 
showing  97  successful  cases,  or  a ratio  of  29  r20-  per  cent.  Wm.  M.  Hasten  15  has  col- 
lected from  American  sources  860  operations  showing  195  cures,  or  22r75  per  cent,  of 
recoveries.  This  would  give  in  all  8380  cases  with  2225  recoveries,  or  26T%  per  cent. 
Certainly  not  an  enviable  showing,  and  yet  the  percentage  in  individual  reports  occa- 
sionally runs  very  high  ; thus  the  statistics  of  the  Annen-Kinderspital  in  1884  showed 
over  50  per  cent,  of  recoveries. 

In  1878,  Agnew1 6 reported  ll,696cases,  of  which  26}  per  cent,  recovered.  Monti, 1 7 of 
Vienna,  in  1884  published  12,736  operations  showing  3409  recoveries,  or  26xij  per  cent. 

Lovette  and  Monroe18  have  published,  in  July  of  this  year,  21,853  operations 
showing  6135  recoveries,  or  28  per  cent. 

Although  our  number  of  intubations  is  still  comparatively  limited,  I have  yet 
been  enabled  to  collect  957  cases  19  showing  252  recoveries,  or  20i}  per  cent,  of  those 
operated  upon.  This,  in  all  probability,  judging  from  a comparison  of  tracheotomy  in 
its  earlier  days,  with  the  result  in  the  present  time,  will  remain  about  the  established 


92 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ratio.  Among  certain  individual  operators  the  proportion  of  recoveries  is  very  much 
higher,  among  others  it  is  far  below  the  mean  percentage.  Taking  into  consideration 
the  liability  to  recovery  in  certain  epidemics,  and  vice  versa  in  others,  I do  not  think 
even  with  improved  instruments,  such  as  are  already  being  experimented  with,  the 
ultimate  ratio  of  recovery  to  operation  will  be  greatly  altered.  This  is  subject  to  the 
proviso  that  the  constitutional  treatment  of  the  disease  remains  unchanged.  Intubation 
and  tracheotomy  are  not  practiced  to  cure  the  disease,  but  simply  that  air  may  be  con- 
veyed to  the  lungs.  This  O’Dwyer’s  tubes  now  accomplish,  and  this  the  various 
tracheotomy  cannula;  have  always  performed.  Accidents  in  either  procedure — the  word 
is  advisedly  used— are  responsible  for  a comparatively  small  number  of  deaths. 

Tracheotomy  gives  us  264  per  cent,  of  recoveries.  Intubation  shows  26f  per  cent., 
not  an  appreciable  difference,  yet  marked  variances  are  found  on  analysis.  Owing  to 
incompletely  reported  cases,  only  a part  of  them  were  available  for  classification.  Sex 
would  seem  to  have  a decided  bearing  upon  the  results  ; thus  of  448  cases  in  which  I 
could  ascertain  the  gender,  236  were  boys  and  212  girls.  Of  the  boys  78  recovered, 
of  the  girls  51,  showing  the  ratio  of  recovery  in  males  to  be  332'o  per  cent.,  in  females 
241.  This  may  be  a mere  coincidence,  although  the  excess  of  recoveries  in  favor  of 
males  was  even  more  marked  in  the  earlier  cases.  Why  this  difference  should  exist  I 
do  not  know,  although  it  may  be  a point  for  further  consideration.  Fisher  and  Briche- 
tau  20  reported  396  tracheotomies,  of  which  225  were  in  males,  of  whom  38  recovered, 
and  171  in  females,  of  whom  29  recovered,  showing  17  per  cent,  of  recoveries  in  both 
sexes.  Bourdillat’s  2 1 analysis  of  1300  cases  also  showed  no  difference  in  favor  of  either 
sex.  Yet  at  various  times  statistics  have  shown  a marked  preponderance  of  recoveries 
in  either  gender. 

1 have  been  able  to  analyze  519  cases  of  intubation  with  reference  to  age  and 
result,  and  will  compare  them  with  Bourdillat’s  22  statistics  of  tracheotomy.  The  143 
intubation  cases  which  recovered  show  a slight  increase  of  11  per  cent,  over  the  gross 
result.  These  may  be  divided  as  follows  : — 


Intubations. 

Recoveries. 

Per  Cent. 

Per  Cent,  of 
Tracheotomy 
Recoveries. 

Under  2 years 

110 

17 

154 

3%  (6JS) 

Between  2 and  24  years 

53 

13 

244 

12% 

Between  2!  and  34  years 

135 

39 

28t% 

17  % 

Between  34  and  44  years 

86 

29 

33tV 

30% 

Between  44  and  5\  years 

60 

17 

35% 

Over  54  years 

75 

28 

3~fV 

394% 

Bourdillat’s  ratio  for  recoveries  under  two  years  seems  much  lower  than  those  of 
other  statisticians;  an  average  of  most  of  them  would  bring  it  to  about  6$,  and  this  I 
have  taken  for  those  years. 

We  find,  then,  that  intubation  practiced  on  children — 

Under  2 years  gives  a gain  of  94  per  cent. 

Between  2 and  2-i  gives  a gain  of  124  per  cent. 

“ 24  and  3J  “ “ lift  “ 

“ 3i  and  4i  “ “ 3ft  “ 

“ 4i  and  5J  “ a loss  of  6ft  “ 

Over  5i  “ “ 2ft  “ 

The  youngest  recovery  in  intubation  was  six  months  old.  In  tracheotomy,  Seout- 
teten23  reports  the  case  of  his  own  child  at  six  weeks,  but  the  correctness  of  his  diag- 
nosis has  been  so  invariably  questioned,  that  it  might  be  eliminated.  The  next  youngest 
tracheotomies  that  recovered  were  those  of  Croft 24  at  five  mouths,  Fisher26  at  six 


SECTION  XIII — LARYNGOLOGY. 


93 


mouths  ; Tait 86  and  Bell 27  each  had  one  at  seven  months.  The  oldest  intubations  to 
recover  were  those  of  Van  Fleet 23  and  Langmann 29  at  eleven  years  and  Austin  G. 
Cases  30  at  ten  and  a half  years.  A child  of  fourteen  years  was  the  oldest  intubation 
recorded.  Recovery  in  tracheotomy  has,  at  rare  times,  been  reported  in  adults. 

Among  the  difficulties  to  be  surmounted  in  the  performance  of  tracheotomy  in 
children  is  obtaining  the  parents’  consent ; this  is  also  experienced  in  intubation, 
although  rarely  to  so  marked  an  extent.  The  difficulty  of  obtaining  an  attendant  who 
is  familiar  with  and  skilled  in  the  after  treatment  of  a tracheotomized  patient  is  one 
of  the  greatest  objections  to  this  interference.  Many  of  the  writers  upon  intubation 
tell  us  that  after  its  performance  no  skilled  attendance  is  necessary.  I think  any  one 
i who  will  closely  study  the  reported  cases  will  see  the  fallacy  of  this  statement.  In  one 
of  the  cases  which  I have  reported,  the  attendant  left  the  house  for  a few  minutes  to 
mail  a letter  ; upon  his  return  he  was  horrified  to  find  the  child  suffocating.  It  died 
during  attempted  removal  of  the  tube,  which  had  become  choked  with  membrane.  But 
there  is  less  danger  in  the  after  treatment  of  intubation  than  of  tracheotomy;  infinitely 
less,  I think.  We  hear  much  of  the  ease  and  facility  with  which  intubation  is  prac- 
ticed ; this  is  misleading  ; to  one  familiar  with  laryngeal  work  it  is  no  great  task. 
I had  a gentleman  try  to  intubate  my  own  larynx,  and  now  I appreciate  the  difficulty 
of  intubation  when  the  obturator  is  not  in  a laryngologist’s  hands.  Inquiry  among 
many  who  practiced  intubation  substantiates  these  views.  If  the  introduction  of  the 
tube  is  difficult,  the  removal  is  infinitely  more  so,  and  not  a few  patients  have  been 
killed  in  the  latter  attempts. 

Tracheotomy  is  an  exceedingly  difficult  operation  in  young  children,  becoming  less 
so  as  the  patients  advance  in  age,  but  always  remaining  an  extremely  delicate  one. 
Much  has  been  written  about  shock.  Now,  patients  do  not  die  of  shock  after  trache- 
otomy. They  do  die  immediately  after  or  sometimes  during  the  operation,  but  it  is 
never  of  shock.  It  is  of  the  effects  of  the  disease  itself  or  the  result  of  accidents  during 
the  operation.  Tracheotomy  requires  ordinarily  at  least  one  skilled  assistant,  intuba- 
tion none.  In  tracheotomy  the  foods  most  readily  assimilated  may  be  given,  in  intuba- 
tion only  solids  or  semi-solids  may  be  ingested.  In  intubation  the  dangers  of  erysipelas 
and  emphysema,  local  and  general,  and  the  consequently  bad  results,  are  not  incurred. 
In  no  case  of  intubation  has  the  tube  been  worn  over  twenty-one  3 1 days,  and  even  that 
was  exceptionally  long,  the  majority  retaining  them  from  the  fourth  to  the  ninth  day. 
In  tracheotomy  it  is  not  at  all  unusual  for  a child  to  wear  a tube  fifty  days,  and  Steiner 
reports  one  in  which  the  tube  was  retained  one  year  and  three  months.  An  unfortunate 
circumstance  in  connection  with  tubage  is  the  dying  of  the  patient  upon  the  introduc- 
tion of  the  instrument,  through  the  crowding  down  of  membrane  or  the  plugging  of 
the  tube.  One  of  the  greatest  advantages  of  intubation  is  that  a patient  can  be  intu- 
bated much  earlier  than  tracheotomized  ; consent  can  more  readily  be  gained  and  the 
attendant,  I think,  will  be  more  likely  to  perform  it ; with  tracheotomy  he  is  apt  to 
postpone  the  performance  a little  more  and  more,  hoping  for  a favorable  turn  and  urged 
thereto  by  the  enormous  labor  entailed  in  the  after  treatment.  One  of  intubation’s  best 
features  undoubtedly  is  that  it  does  not  preclude  a subsequent  tracheotomy.  Another 
feature  of  inestimable  value  is  that  the  air  reaches  the  lungs  in  the  normal  manner. 

The  grave  question  now  remains,  When  shall  tubage  be  done  and  when  tracheotomy 
i performed  ? 

1.  All  things  being  equal,  I would  always  intubate  when  the  patient  is  under  three 
and  one-half  years  of  age. 

2.  Between  the  ages  of  three  and  one-half  and  five  years  I would  be  regulated,  of 
course,  by  individual  circumstances,  with  a preference  for  tracheotomy. 

3.  Over  five  years  of  age  I should  perform  tracheotomy. 

4.  In  adults  I would  never  tracheotomize,  but  willingly  test  intubation. 


94 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


5.  Among  poor  people,  irrespective  of  age,  I would  always  intubate.  While  it  may 
sound  harsh  to  draw  such  class  distinction,  good  reasons  are  forthcoming.  The  general 
results  of  intubation  are  about  equal  to  those  of  tracheotomy.  Skilled  attendance, 
such  as  is  always  required  after  tracheotomy,  can  only  be  procured  for  considerable 
purchasing  power,  and  is,  in  consequence,  only  available  where  people  have  means. 
While  the  operator  himself  may  be  willing  to  give  his  own  valuable  time,  he  may  owe 
to  other  patients  attendance  that  may  be  of  as  much  value  to  them  as  to  the  child 
operated  upon. 

6.  Intubation  should  never  be  performed  at  any  age  when  there  is  a strong  proba- 
bility  that  the  trachea  is  crowded  with  membrane. 

7.  Where  skilled  assistants  cannot  be  obtained,  intubation  should  al  ways  be  practiced. 

I should  not  like  to  close  the  paper  without  a slight  tribute  to  the  labors  of  Dr. 

O’ Dwyer,  who,  through  his  perseverance  and  patient  period  of  experimentation,  has 
placed  in  our  hands  a procedure  that  will  probably  save  many,  many  lives.  Had  he, 
upon  the  incipiency  of  the  experiments,  followed  Bouchut’s  plan  of  immediately  pub- 
lishing his  results,  would  it  not  again  have  shared  a like  fate  ? Which  of  us  may  not 
yet  have  personal  cause  for  a debt  of  gratitude  to  this  modest  inventor  ? 


OPERATORS,  NUMBER  OF 

CASES 

OPERATED 

UPON  AND  NUMBER 

OF  RECOVERIES. 

Operator. 

No.  op 

No.  op  Re- 

Operator. 

No.  OF 

No.  of  Re- 

Cases. 

coveries. 

Cases. 

coveries. 

Jos.  O’Dwyer, 

137 

27 

L.  U.  Dunning, 

7 

2 

E.  E.  Waxharn, 

131 

34 

J.  Eichberg, 

6 

2 

Dillon  Brown, 

87 

18 

H.  H.  Mudd, 

6 

2 

F.  Huber, 

47 

20 

I.  H.  Hance, 

6 

1 

J.  N.  Bleyer, 

42 

11 

J.  E.  Winters, 

6 

0 

D.  O’Shea, 

37 

14 

J.  Salinger,* 

6 

3 

W.  P.  Northrup, 

32 

6 

Hopkins, 

6 

6 

A.  B.  Strong, 

31 

1 

H.  0.  Bates, 

6 

3 

C.  E.  Denhard, 

24 

10 

W.  H.  Preston, 

6) 

F.  Van  Fleet, 

22 

7 

W.  P.  Boles, 

2 

2 

D.  C.  Cocks, 

21 

6 

H.  L.  Smith, 

2 j 

T.  H.  Meyers, 

21 

4 

Carl  Beck, 

5 

4 

E.  E.  Montgomery,'* 

21 

11 

James  McManus, 

5 

2 

A.  Caille, 

15 

5 

F.  K.  Priest, 

5 

0 

W.  Cheatham, 

15 

1 

Forscheimer, 

5 

2 

G.  H.  Cocks, 

14 

4 

G.  W.  Gay, 

4 

. 0 

E.  F.  Ingals, 

12 

3 

F.  C.  Shaffer, 

4 

0 

J.  Tasher 

11 

4 

Geo.  Thilo. 

4 

3 

W.  K.  Simpson, 

10 

0 

H.  D.  Ingraham, 

3 

0 

J.  A.  Anderson, 

10 

1 

A.  S.  Hunter, 

3 

0 

E.  L.  Cocks, 

10 

3 

G.  W.  Mason, 

3 

1 

J.  J.  Reid, 

10 

4 

F.  W.  Merriam, 

3 

2 

Geo.  McNaughton, 

10 

2 

S.  A.  McWilliams, 

3 

0 

C.  G.  Jennings, 

10 

0 

H.  Boenning, 

3 

1 

A.  E.  Hoadley, 

9 

0 

M.  J.  Stern,* 

3 

1 

F.  Henrotin, 

9 

3 

Rehfuss,'* 

3 

2 

H.  W.  Berg, 

8 

2 

N.  S.  Roberts, 

o 

1 

David  Prince, 

2 

2 

W.  E.  Shaw, 

2 

0 

W.  L.  Carr, 

2 

0 

J.  L.  Mullfinger, 

2 

1 

Hailes, 

2 

2 

S.  Solis-Cohen,* 

2 

0 

J.  AV.  Niles, 

1 

0 

E.  C.  Morgan, 

1 

0 

B.  T.  Shimwell* 

4 

2 

J.  B.  Wheeler, 

1 

0 

L.  L.  Palmer, 

1 

0 

H.  F.  Ivins, 

1 

0 

A.  G.  Case, 

1 

1 

F.  Donaldson,  Jr., 

1 

0 

Frank  Tipton, 

1 

1 

Charles  Dennison, 

1 

1 

Langmann, 

1 

1 

E.  D.  Furgueson, 

1 

0 

Rihl, 

1 

0 

James  Collins, 

1 

0 

T.  G.  Morton, 

1 

0 

No.  of  Operators,  75. 

No.  of  Cases 

, 957.  No.  of  Recoveries 

, 252. 

* Personally  communicated  to  writer  from  notes. 


SECTION  XIII — LARYNGOLOGY. 


95 


REFERENCES  AND  BIBLIOGRAPHY  OF  INTUBATION. 

Medical  Record,  Now  York.  1885,  Feb.  21st. 

« “ “ “ 1886,  xxix,  410. 

" “ “ “ 1886,  xxix,  641. 

“ “ “ “ 18S6,  xxx,  437. 

“ “ “ “ 1886,  xxx,  645. 

“ “ “ “ 1886,  xxx,  6S3. 

“ “ “ “ 1887,  xxxi,  26. 

“ “ “ “ 18S7,  xxxi,  108. 

“ “ “ “ 1887,  xxxi,  324. 

“ “ “ “ 1887,  xxxi,  677  to  687. 

“ “ “ “ 1S87,  xxxi,  608. 

“ “ “ “ 1887,  xxxi,  705  to  707. 

“ “ “ “ 1887,  July  2d,  xxxn. 

“ “ “ “ 1887,  July  9th,  xxxii. 

“ “ “ “ 1887,  xxxii,  99,  106. 

Neic  York  Medical  Journal.  1885,  xlii,  145. 

“ “ “ “ 1886,  xliii,  384. 

“ “ “ “ 1886,  xliv,  373.  . 

“ “ “ “ 1886,  xliv,  322. 

“ “ “ “ 1887,  xlv,  238. 

« “ “ “ 1887,  xlv,  273. 

“ “ “ “ 1887,  xlv,  624. 

“ “ “ “ 1887,  xlv,  640. 

“ “ “ “ 1887,  xlvi,  11. 

“ “ “ “ 1887,  xlvi,  No.  5. 

Journal  American  Medical  Association.  18S6,  VI,  147. 

« “ “ “ 18S6,  vi,  1S6. 

“ “ “ “ 1886,  vi,  426. 

“ « “ “ 1886,  vii,  35. 

“ “ “ “ 1887,  viii,  199. 

“ “ “ “ 1887,  viii,  342. 

“ “ " “ 1887,  viii,  337. 

“ “ « “ 1887,  viii,  359. 

“ “ “ “ 1887,  viii,  291. 

“ “ “ “ 18S7,  viii,  701. 

“ “ “ “ 1887,  ix,  135. 

Letter  to  E.  Fletcher  Ingals.  Reprint  from  the  New  York  Medical  Journal,  July  2d  and 
9th,  1887. 

Statistical  Records  of  Intubation,  Medical  Record,  July  23d,  1887. 

New  York  Medical  Journal,  August  8th,  1885. 

Transactions  of  the  American  Laryngological  Association,  1887. 

Chicago  Medical  Journal  and  Examiner.  1885,  L,  475. 

“ “ “ “ “ 1885,  LI,  511. 

“ “ “ “ “ 1886,  liii,  132. 

“ “ “ “ “ 1886,  in,  214. 

“ “ “ “ “ 1885,  Li,  401. 

Medical  and  Surgical  Reporter.  1886,  LV,  586. 

New  Yorker  Med.  Presse.  1887,  m,  259. 

“ “ “ “ 1887,  June. 

Medical  Register.  1887,  I,  174. 

“ “ 1887,  I,  146. 

Medical  News.  1887,  l,  341. 

“ “ 1887,  l,  630. 

Maryland  Medical  Journal.  1886,  xvi,  67. 

“ “ “ 1886,  xvi,  168. 


96 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Medical  Review,  Pittsburgh.  1887,  i,  114. 

Weekly  Medical  Review,  St.  Louis.  1887,  XT,  57. 
Pacific  Medical  and  Surgical  Journal.  1887,  XXX,  129. 
Chicago  Medical  Times.  1887-  8,  xix,  53. 

Cincinnati  Lancet  and  Clinic.  1887,  n.s.,  xvn,  97. 

“ “ “ “ 1887,  n.s.,  xvni,  321. 

Hahnemannian  Monthly,  June,  1886. 

American  Practitioner  and  News.  1886,  N.S.,  II,  321. 

St.  Louis  Medical  and  Surgical  Journal.  1887,  Lll,  115. 
American  Lancet,  Detroit.  1886,  n.s.,  x,  401. 

Canadian  Practitioner,  Toronto.  1887,  XU,  1. 

Archives  of  Pediatrics,  1885,  II,  657. 

“ “ “ 1886,  in,  215. 

“ “ “ 1887,  iv,  154. 

Medical  Age,  Detroit.  1886,  iv,  313. 

Mississippi  Valley  Medical  Monthly.  1886,  vi,  345. 
Albany  Medical  and  Surgical  Journal.  1887,  II,  331. 
Boston  Medical  and  Surgical  Journal.  1S87,  clvi,  518. 
American  Journal  of  Obstetrics.  1886,  June  17th. 


1 Si  omnibus  his  non,  sero,  vel  frustra  tentatis,  morbus  sit  maxime  reeens  et  strangulans 
staturn  post  acerbam  prognosim  instituenda  exit  bronchotome.  Stoll,  aphorism,  page  32,  bind 
ob  1786. 

2 Guersant  Dietionnaire  de  Medecine,  1835. 

3 Med.-Chir.  Transactions,  vi,  1816,  p.  151. 

* Trousseau,  “Tracheotomie  Dietionnaire  de  Medecine,”  1835. 
b Communication  to  Erench  Academy,  July,  1825. 

6 Trousseau,  op.  cit. 

2 “ Dietionnaire  de  Medecine,”  Paris,  1835. 


Operators. 

No.  op 
Cases. 

Recoveries. 

Operators. 

No.  OP 
Cases. 

Recoveries. 

8 Amussat, 
Baudelocque, 

6 

0 

Serdy, 

6 

4 

15 

0 

Roux, 

4 

0 

Blandin, 

5 

0 

Trousseau, 

80 

20 

B retonneau, 

18 

4 

Velpeau, 

6 

.0 

(a)  Bull,  de  V Acad,  de  Med.,  1839,  1858-9. 
Cohen’s  “Croup,”  Philadelphia,  1874. 


Operators. 

No.  of  Cases. 

Recoveries. 

Gosselin, 

23 

0 

Michon, 

20 

2 

Langier, 

. f Before  1848, 

Nelaton,  | Aftor  1848| 

8 

23  1 oa  ( Before  1848,  0 1 

13  j ( After  1848,  13  J 

1 

3 

Monod,  Jr.,  (About) 

40 

0 

Sheirry  (in  Children), 

37 

3 

“ (in  Adults), 

3 

0 

Malgaigne, 

Bardinet  (and  Confreres  at  I 

8 (or  ten) 

1 

Amoges),  57 

17 

Sausier  (Troges), 

6 

3 

Beylard  (Paris), 

13 

4 

Moynier  “ 

17 

8 

Archainbault  (Paris), 

21 

8 

Perrochand  (Boulogne), 

3 

2 

Delarne  (Paris), 

3 

1 

Salvis  (Belleville) 

6 

3 

Viard  (Montbard), 

2 

1 

Petel  (Cateau), 

9 

5 

Baudin  (Nautua), 

4 

3 

Dubarry  (Condom), 

5 

2 

SECTION  XIII — LARYNGOLOGY. 


97 


(b)  Bull,  de  l’ Acad.  Med.,  xxiv,  page  231. 

Gaz.  Held.,  Dec.  3d,  1858,  page  844. — Cohen’s  “ Croup.” 


Operators. 

No.  op 
Cases. 

Recoveries. 

Operators. 

No.  op 
Cases. 

Recoveries. 

Richet, 

9 

5 

Richard, 

Demarquay, 

5 

2 

Follin, 

7 

2 

6 

2 

Broca, 

12 

6 

(c)  Bull,  de  I’Acad.  Mtd.,  xxiv,  page  233. 


Cohen’s  “ Croup.” 

Operators. 

No.  op  Cases. 

Recoveries. 

Rousseau  (1851-4,  private  practice), 

24 

14 

Isnard, 

4 

2 

Baizeau  (Paris), 

12 

2 

Brockel  (Strasbourg), 

33 

12 

Schoolhammer  (Haut  Rhin), 

7 

6 

Other  Operators, 

43 

16 

Calvet  (Catred), 

23 

13 

Hennette  (Brussels), 

8 

4 

Sanne’s  “ Diphtheria,”  St.  Louis,  18S7,  page  467,  8, 

Operators.  No.  of  Tracheotomies. 

Recoveries. 

Antonio  Maria  Babbosa, 

23 

9 

Theotonio  da  Silva, 

21 

8 

Other  Operators,  15  4 


59 

(a)  Gill’s-Sanne’s,  op.  cit.,  page  470. 

Operators. 

Henriet, 

Warlomont  (St.  Peter’s  Hospital  at  Brussels), 


(a)  Gill’s-Sanne's,  op.  cit.,  page  471. 

Operators  and  Country. 

Passawant,  Frankfort,  from  1851  to  1882, 

Baum,  Svettingen, 

Fock  and  others,  Magdeburg, 

Roser,  Marbourg, 

Mide  and  others,  Braunschweig, 

Simon,  Rostvik  (one  in  an  adult  terminated 
fatally), 

Borow,  Koenigsburg, 

Schmidt, 

Leipzig,  City  Hospital  from  1878  to  1883. 
Peltzer,  Brennen,  from  Oct.,  1883  to  March,  1884, 
Bartels,  Kiel, 

Man  Bartels,  Berlin,  statistics  of  the  operations 
performed  in  the  service  of  Prof.  Wilms,  at  the 
Batheanien  Hospital,  from  1S61  to  1872,  and 
comprise  the  100  published  by  Siiterboch  in 
1867, 

Eberth,  Berlin,  1857  to  1865, 

Busch,  Berlin, 

Von  Kopl, 

Morath, 

Stelzner,  Dresden, 

Muller,  Cologne,  1862,  1869, 

Molard  Ziniski,  Lemberg  (one  an  adult), 
Oelschlaeger,  Danzioy,  1856  to  1869, 

Reiffer,  Frauenfeld, 

Heuter,  Rostock, 

Birnbaum,  Darmstadt,  1873  to  1883, 

Van  Arsdale,  Annals  of  Surgery,  Vol.  i,  No.  2, 1885, 
Harmer,  Munich, 

Fifty-eighth  Congress  of  German  Nat.  and  Physi- 
cians, Strassburg,  Sept.  18th  to  23d,  1885. 
( Med . Record,  Nov.  14th,  1885),  Rauke, 
of  Munich,  Tracheotomy,  74  years, 


Vol.  IV— 7 


21 


Cases. 

Recoveries. 

8 

4 

35 

8 

43 

12 

No.  op  Cases. 

Recoveries. 

229 

67 

31 

12 

43 

18 

42 

19 

81 

21 

22 

6 

59 

7 

15 

2 

310 

67 

88 

12 

61 

17 

335 

103 

13 

6 

72 

10 

17 

11 

1 

1 

12 

4 

45 

15 

2 

0 

12 

1 

18 

8 

29 

7 

140 

47 

88 

76 

17 

2 

45 

19 

1837 

558 

98 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Gill’s-Sanne’s,  op.  cit.,  page  472-3. 


Operators  and  Country. 
Billroth,  Zurich. 
Revilliod,  Geneva, 
D’Espine,  Geneva, 
Picot,  Geneva, 
Papin,  Genova, 


(a)  Gill’s-Sanne’s,  op.  cit.,  page  473. 


No.  of  Cases. 
12 
87 
15 
4 
30 

148 


Recoveries. 

1 

38 

6 

3 

9 

57 


it 


Operators  and  Country. 
Spence,  Edinburgh, 
Buchanan,  Glasgow, 
Comchoshank, 

H.  W.  Fuller,  Statistics  of, 
Conway  Evans, 

Henry  Smith,  London, 
Ronson,  Nottingham, 
West,  London, 


No.  of  Cases. 
87 
39 
11 
7 
5 
3 
3 

30 


Recoveries. 

28 

13 

8 

3 

1 

0 

0 

7 


(a)  Cohen’s,  op.  cit. 

( b ) Gill’s-Sanne’s,  op.  cit.,  page  474. 


Operators. 

Dickinson, 

Fagge, 


Cases.  Recoveries. 
18  6 

43  7 


Operators. 

Gee  from  1853  to  1878, 
R.  W.  Parker, 


No.  OF 
Cases. 
34 
32 


Recoveries. 

3 

17 


127  33 


Dickinson,  Transactions  of  the  Royal  Med.-Chirurg.  Society  (1879). 


Hospitals. 

St.  George’s  (one  of  the  fatal  cases  was  16  years  old), 
Dreadnought  Hospital  Ship, 

Metropolitan  Free  Hospital, 

Hospital  for  Sick  Children, 

King’s  College  Hospital, 

Middlesex  Hospital, 

St.  Mary’s  Hospital, 

Addenbrooke’s  Hospital,  Cambridge, 


No.  of  Cases. 
6 
1 
1 
3 
1 
6 
1 
1 

20 


Recoveries. 

3 
0 
0 
0 
0 
0 
0 
1 

4 


(c)  Same,  op's  cit. 

18  “ Annals  of  Anatomy  and  Surgery,”  1881. 

16  Agnew,  “System  of  Surgery,”  Vol.  m,  1878. 

17  “ Annals  of  Anatomy  and  Surgery,”  Vol.  i,  page  5S1. 

18  Lovett  & Monroe,  Amer.  Jour.  Med.  Sciences,  July,  1887. 

19  Appended  Statistics. 

90  “ Traitement  du  Croup  ou  Angine  laryngee  diphtheritique,”  seconde  Edition,  Paris,  1863. 

91  Bourdillat,  Bull.  Soc.  Med.  Ho.,  Paris,  1887,  page  39.  Cohen,  op.  cit. 

99  Bourdillat,  op.  cit. 

93  Am.  Jour.  Med.  Sciences,  1844,  April,  page  466. 

91  Lancet,  Nov.,  1880,  page  849. 

93  Deutsche  Medizinisehe  Wockenschrift,  No.  45,  1S87. 

96  British  Med.  Journal,  April  15th,  1877,  page  391. 

97  Some  Ed.  Med.  Journal,  1861,  page  956.  Philosophical  Transactions,  Vol.  VII,  No.  411, 

page  448,  1719,  1733.  Cohen,  in  Ashhurst’s  Encyl.  of  Surg.,  Vol.  v,  page  704. 

98  N.  Y.  Med.  Journal,  1887,  Vol.  xxxil,  page  103. 

99  N.  Y.  Medizinisehe  Presse,  1887,  B.  ill,  Soito  259. 

30  Med.  Review,  Pittsburgh,  1S87,  Vol.  i,  page  114. 

31  Montgomery,  personal  communication. 


SECTION  XIII — LARYNGOLOGY.  99 

DISCUSSION. 

Dr.  C.  Dennison,  of  Denver,  Col. , spoke  of  the  influence  of  the  unwillingness  of 
the  surgeon  to  operate,  as  well  as  the  liberty  granted  hy  parents  to  operate  as  a der- 
nier ressort,  as  militating  against  what  would  otherwise  be  the  favorable  standing  of 
intubation  as  compared  with  tracheotomy.  That  is,  the  more  unfavorable  cases 
operated  ou  by  intubation  (as  the  surgeon  can  delay  so  long)  unduly  lessens  the  per- 
centage of  success  with  this  method.  The  great  variety  of  cases  entering  into  the 
calculations  (whether  oedema  glottidis,  true  croup,  or  genuine  diphtheria),  and  some 
uncertainty  perhaps  as  to  the  question  of  diagnosis,  were  mentioned  as  elements  of 
uncertainty  in  deciding  between  tracheotomy  and  intubation. 

Dr.  Dennison  referred  to  his  own  experience  with  the  operation  of  intubation, 
which  comprised  three  cases,  two  of  membranous  croup,  which  recovered,  and  one 
of  diphtheria,  which  terminated  fatally.  The  latter  case  was  very  instructive  iu 
showing  the  unsuitableness  of  the  gag  which  goes  with  the  O’ Dwyer  set  of  tubes. 
The  patient,  a girl  about  eight  years  old,  in  struggling,  hit  the  long  descending 
handles  of  the  gag  with  the  shoulder  and  the  gag  was  thrown  out,  when  the  jaws 
closed  on  the  operator’s  finger,  and  the  teeth  penetrated  nearly  to  the  bone.  The 
operation  was  completed,  and  then,  when  the  Doctor  had  turned  to  put  his  finger  into 
an  antiseptic  solution,  the  child  caught  hold  of  the  silk  thread  connected  with  the 


tube  and  pulled  the  tube  out.  The  tube  was  immediately  re-introduced,  but  the 
awkwardness  of  the  gag  led  the  operator  to  devise  another,  which  is  shown  in  the 
accompanying  cut.  The  features  which  are  new  about  this  instrument  are  the  par- 
! tially  swivel  motion  of  the  troughs  to  receive  the  jaws,  and  the  new  device  to  force 
the  jaws  open,  the  cross  bar  between  the  handles  having  attached  to  it  a spring  to 
free  the  teeth  against  a stop  on  the  lower  bar. 

Messrs.  Tiemann  & Co.,  of  New  York,  will  make  the  instrument  with  the  needed 
corrections  stated. 

Prof.  W.  E.  Casselberry,  of  Chicago,  said — In  performing  the  operation  it  is 
better  to  use  the  arytenoid  cartilages  as  a guide  for  the  finger.  In  this  position  the 
finger  is  practically  in  the  oesophagus,  and  if  the  finger  is  there  the  tube  will  not  go 
there,  and  is  more  easily  introduced  in  the  larynx.  Practice  on  the  cadaver,  I 
regard  as  essential ; a foetus  anywhere  near  term  will  answer  for  this,  and  there  is 
little  excuse  for  an  attempt  without  such  preliminary  practice.  A finger  stall  should 
be  worn.  A physician  of  Chicago  lost  his  life  by  diphtheria,  through  having  his 
finger  bitten.  In  closing,  I would  quote  Prof.  Fenger’s  remarks:  “I  would  per- 
form intubation  and  have  the  tracheotomy  instruments  on  the  table.” 


100 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Dr.  Coomes,  of  Louisville,  Ky. , said  that  the  handle  of  a small  teaspoon  passed 
back  and  forced  between  the  jaws  at  the  angle,  will  always  result  in  causing  the  child 
to  open  its  mouth.  He  advised  masking  the  nose  and  mouth  while  examining  diph- 
theritic throats  and  noses.  He  said  that  Brandies,  of  Louisville,  Ky. , had  saved  a 
patient’s  life,  some  twenty  years  ago,  by  introducing  an  ordinary  catheter  and  per- 
mitting it  to  remain  twenty-four  hours. 

Dr.  Waxham,  of  Chicago — I have  been  interested  in  this  very  valuable  paper, 
doubly  so  as  the  conclusions  of  the  author  coincide  so  closely  with  my  own. 

It  has  been  my  privilege  to  report  one  thousand  and  seven  cases  in  another 
Section  (the  Section  on  Diseases  of  Children).  Of  this  number  there  were  two 
hundred  and  sixty-six  recoveries,  or  26. 54  per  cent.  The  ages  were  recorded  in  six 
hundred  and  sixty-one  cases ; the  average  age  being  three  years  and  three  months. 
I cannot  agree  with  the  author  in  the  statement  that  we  should  perform  intubation 
upon  the  younger  patients  and  tracheotomy  upon  the  older  ones,  for  these  statistics 
show  that  the  operation  is  not  only  more  successful  in  the  young  children,  but  in  the 
older  ones  as  well.  In  the  cases  reported  by  myself  the  percentage  of  recoveries 
among  children  five  years  old  was  33. 92  ; among  those  seven  years  old  50. 1 , while 
among  those  of  nine  and  ten  years  it  was  also  50. 

It  seems  hardly  fair  to  compare  tracheotomy  as  performed  by  European  operators 
with  intubation  as  performed  by  American  surgeons.  In  America  operative  proced- 
ures are  seldom  allowed  excepting  as  a last  resort,  while  in  Europe  tracheotomy  is 
performed  earlier,  especially  by  the  most  successful  operators;  some,  as  Herr 
Banke,  of  Munich,  operate  as  soon  as  there  is  the  first  symptom  of  laryngeal 
invasion,  admitting  that  the  operation  is  sometimes  performed  upon  those  who 
might  recover  without  it.  Tracheotomy  in  America  is  not  a brilliant  success,  because 
the  operation  is  seldom  performed  early.  It  therefore  seems  more  fair  to  compare 
intubation,  not  with  tracheotomy  as  performed  in  Europe,  but  with  tracheotomy  as 
performed  here . 

The  feeding  of  a patient  after  intubation  is  highly  important,  and  the  physician 
should  personally  superintend  it.  We  should  endeavor  to  find  what  the  child  will 
swallow  best.  Not  long  since  I had  a little  patient  that  was  extravagantly  fond  of 
bananas,  which  she  would  eat  without  the  least  difficulty,  while  she  would  refuse 
almost  entirely  all  other  food.  Bananas  and  cracked  ice  formed  the  diet  for  several 
days  together,  with  a very  small  amount  of  semi-solid  food.  Not  a very  nourishing 
diet,  to  be  sure,  but  sufficient  to  support  life.  Some  patients  swallow  with  very  little 
difficulty,  indeed,  while  others  swallow  poorly.  If  the  head  of  the  tube  fits  too 
tightly  in  the  larynx  there  will  be  greater  difficulty.  The  artificial  epiglottis  is  of 
great  assistance  in  swallowing.  In  usiug  the  rubber  attachment,  however,  one  must 
first  see  that  it  is  properly  attached  to  the  tube,  and  that  it  does  not  become  dis- 
arranged during  its  introduction . 

It  appears  to  me  that  the  proper  method  of  comparing  the  value  of  intubation 
and  tracheotomy  is  not  by  comparing  the  number  of  cases  operated  upou  alone, 
but  also  by  comparing  the  proportion  of  recoveries  in  each  case  with  the  total  num- 
ber requiring  an  operation.  For  example,  taking  one  thousand  cases  of  croup,  how 
many  will  be  saved  by  tracheotomy.  Wo  may  safely  say  that  the  operation  will  not 
be  allowed  in  more  than  one-fourth  of  the  cases,  or  two  hundred  and  fifty.  If  we 
save  twenty-five  per  cent,  of  this  number,  which  I believe  is  above  the  average,  we 
will  thus  save  sixty-three  of  the  one  thousand.  On  the  other  hand,  out  of  the  one 
thousand  cases  we  would  be  allowed  to  perform  intubation  upon  every  one,  and  if  we 
save  twenty-five  per  cent.,  which  is  below  the  average,  it  will  give  a total  of  two 
hundred  and  fifty  saved  in  contrast  to  the  sixty-three  by  tracheotomy. 


SECTION  XIII — LARYNGOLOGY. 


101 


Intubation  has  become  a thoroughly  established  operation,  aud  its  future  uo 
doubt  will  be  more  brilliant  than  its  past. 

Dr.  M.  J.  Stern,  of  Philadelphia,  in  closing  the  discussion,  remarked — I have 
seen  one  case  of  chorea  of  the  cords.  A young  female,  who  had  just  recovered  from 
post-diphtheritic  paralysis,  presented  herself  for  a slight  catarrhal  affection,  at  the 
office  of  Dr.  J.  Solis-Cohen,  whom  I was  assisting.  She  was  extremely  hysterical, 
i aud  after  the  younger  Dr.  Cohen  and  myself  discoursed,  in  her  presence,  of  some  rare 
affection,  she  always  presented  herself  some  few  days  later  with  characteristic  symp- 
toms of  the  disease  described.  On  the  day  mentioned,  I examined  her  larynx,  found 
it  normal,  aud  turned  to  the  medicine  chest  to  obtain  some  non-irritating  application. 

)On  my  return  I was  horrified  to  find  her  suffocating.  I was  sure  she  had  no  foreign 
body  in  her  mouth,  and  hurriedly  got  a tracheotomy  knife,  laid  her  on  the  floor,  and 
then  emptied  a pitcher  of  ice  water  over  her  face.  To  my  relief  she  drew  a deep  in- 
spiration, and  was  soon  able  to  be  carried  home.  A laryngoscopic  examination  could 
not  be  obtained  for  four  or  five  days,  and  when  it  was  obtained,  the  bands  showed  a 
peculiar  wavy  motion,  and  quick  jerks  toward  each  other,  and  she  was  again  seized 
with  a paroxysm.  It  was  accompanied  by  a peculiar  bark-like  cough.  She  was 
unable  or  unwilling  to  talk.  Spontaneous  cure  iu  about  three  or  four  weeks. 

KALAMAZOO  ACAD  EM'S 
OF 

MEDICINE. 

Dr.  M.  F.  Coomes,  of  Louisville,  Ky.,  read  a paper  entitled — 

DELETERIOUS  EFFECTS  OF  TOBACCO  ON  THE  AIR  PASSAGES. 

EFFETS  DELETERES  DU  TABAC  SUR  LES  VOIES  RESPIRATOIRES. 

DIE  SCHADLICHEN  WIRKUNGEN  DES  TABAKS  AUF  DIE  LUFTWEGE. 

BY  M.  F.  COOMES,  A.M.,  M.D., 

Of  Louisville,  Ky. 

For  a period  of  sixteen  years  I have  observed  carefully  the  effects  of  tobacco  on  the 
air  passages.  These  observations  have  been  made  upon  persons  in  all  the  walks  of  life, 
of  all  ages — from  twelve  or  fourteen  years  to  the  centenarian. 

The  consumption  of  tobacco  in  the  United  States  is  mainly  by  chewing,  and  espe- 
cially is  this  true  of  the  population  of  the  rural  districts.  The  cigar  smoker  comes 
i second  in  the  order  of  a consumer,  as  regards  quantity,  then  the  pipe  smoker,  then  the 
cigarette  smoker,  then  the  class  that  take  snuff  by  the  nose — the  ordinary  snuffer,  who 
is  met  with  all  over  the  world — and  lastly,  what  is  known  in  the  southwestern  part  of 
the  United  States — for  I believe  that  it  is  confined  to  that  locality  in  the  main — the 
snuff  dipper,  or  commonly  called  a “dipper.” 

This  latter  mode  of  using  tobacco  is  confined  almost  exclusively  to  women  in  the 
lower  and  medium  walks  of  life.  Many  of  them  become  absolute  slaves  to  it,  using 
enormous  quantities  of  the  snuff  which  in  the  market  is  known  as  Scotch  snuff,  and  is 
manufactured  from  tobacco  stems  and  cigar  stumps.  It  is  used  by  dipping  a mop  into 
the  snuff,  and  then  introducing  the  mop  into  the  mouth.  Many  of  them  keep  con- 


f 


102 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


stantly  rubbing  their  gums  and  teeth  with  the  mop,  while  others  simply  suck  the  mop 
or  chew  it.  In  individuals  who  use  tobacco  in  the  above  manner  the  gums  are  usually 
very  red  and,  as  a rule,  they  are  pushed  well  down  on  the  teeth.  The  buccal  surface 
of  the  cheeks,  and  in  many  of  them  the  entire  buccal,  pharyngeal  and  laryngeal  mucous 
surfaces  are  iu  a state  of  congestion  similar  to  that  which  is  met  with  in  persons  who 
are  habitual  cigar  or  pipe  smokers.  I think  that  there  can  be  no  doubt  that  many  of 
the  “ dippers  ”of  snuff  induce  a chronic  inflammatory  state  of  the  larynx,  trachea  and 
larger  bronchial  tubes  by  inhaling  the  tobacco  in  this  finely  comminuted  state.  A sim- 
ilar condition  is  met  with  in  persons  who  handle  tobacco  in  the  leaf  or  comparatively 
dry  state.  Within  the  past  year  I saw  a case  of  phthisis  pulmonalis  which  I am  satis- 
fied was  hastened  to  a fatal  termination  by  constantly  inhaling  the  dust  from  tobacco, 
which  kept  the  air  passages  aud  lungs  in  a perpetual  state  of  irritation. 

Before  leaving  the  subject  of  snuff  dipping,  I will  state  that  one  of  the  worst  cases 
of  tobacco  amblyopia  that  I ever  saw  resulted  from  dipping  snuff.  So  far  as  local 
effects  of  tobacco  are  concerned,  I believe  that  the  least  amount  of  harm  results  from 
chewing.  A chronic  pharyngitis  is  one  of  the  most  common  results  from  its  use  iu 
this  way,  and  in  this  connection  I may  say  that  I believe  that  many  a clergyman' s sore 
throat  is  nothing  more  nor  less  than  a tobacco  throat , which  may  result  from  either  chew- 
ing or  smoking. 

I have  seen  two  well  marked  cases  of  buccal  inflammation  resulting  from  chewing 
tobacco.  The  first  occurred  in  the  person  of  a young  mechanic  who  had  been  chewing 
fora  number  of  years.  The  entire  buccal  cavity  and  pharynx  were  acutely  inflamed, 
the  mucous  membrane  being  as  red  as  scarlet.  After  making  diligent  inquiry  into 
the  history  of  his  case,  I could  find  nothing  to  account  for  the  trouble,  unless  it  was 
the  tobacco.  I advised  him  to  quit  the  tobacco,  and  gave  him  a soothing  mouth 
wash. 

In  the  course  of  eight  days  he  was  well,  and  asked  my  advice  about  using  tobacco 
again.  I told  him  to  try  it.  He  did  so,  with  the  result  of  having  a very  sore  mouth 
and  pharynx  for  several  days,  which  got  well  under  the  plan  of  treatment  pursued  in  the 
former  instance.  He  made  numerous  efforts  to  indulge  in  his  old  habit,  but  always 
with  the  same  unpleasant  results.  The  second  case  was  similar  to  the  first,  but  much 
less  severe. 

The  greatest  injury  to  the  air  passages  from  the  use  of  tobacco  results  from  smoking. 

The  habit  that  many  persons  have  of  carrying  the  smoke  into  their  lungs  often  develops 
irritation  of  the  mucous  membrane  lining  the  trachea  and  larger  bronchial  tubes,  which 
finally  results  in  chronic  inflammation  of  the  parts  thus  irritated. 

It  is  not  an  uncommon  thing  to  find  the  nasal  mucous  membrane  of  those  who  exhale 
smoke  through  their  noses  in  a hypertrophic  and  hemorrhagic  condition.  In  such  cases 
the  hemorrhage  is  not  profuse,  but  the  handkerchief  is  often  soiled  with  blood  as  the 
result  of  an  ordinary  effort  at  “ blowing  the  nose.  ” Such  membranes  bleed  upon  the 
slightest  provocation.  In  many  persons  thus  affected  the  sense  of  smell  is  impaired  ; . J 

in  some  instances  it  is  almost  destroyed. 

In  numerous  instances  I have  seen  the  entire  anterior  portion  of  the  nasal  mucous 
membrane  in  a condition  which  resulted  in  the  formation  of  a bloody  crust  or  scab,  the 
removal  of  which  was  often  followed  by  considerable  hemorrhage. 

In  such  cases  the  cessation  of  the  tobacco  was  usually  followed  by  marked  improve- 
ment in  the  course  of  a few  days.  A snuff  composed  of  powdered  borax  ss,  and 
powdered  camphor  gr.  x,  affords  great  relief  in  such  cases,  by  inducing  increased 
activity  in  the  glands  of  the  nasal  membrane. 

The  question  very  naturally  suggests  itself,  why  is  it  that  the  throats  of  smokers 
are,  as  a rule,  in  a worse  condition  than  those  of  chewers.  There  are  two  reasons 
why  smokers  suffer  more  than  chewers,  the  chief  one  being,  I think,  the  fact  that  an 


SECTION  XIII — LARYNGOLOGY. 


103 


inferior  grade  of  tobacco  is  used  by  the  smoker ; secondly,  the  smoke  is  carried  into  the 
mouth  hot,  and  were  it  not  for  the  constant  secretion  which  goes  on,  the  walls  of  the 
mouth  would  soon  become  covered  with  nicotine,  but  instead,  a portion  of  it  is  absorbed, 
and  the  remainder  expectorated  with  the  saliva  or  swallowed.  It  is  possible  that  all  of 
this  irritation  is  not  due  to  the  presence  of  nicotine,  but  to  the  burning  of  potash  salts, 
which  is  present  in  large  quantities  in  all  grades  of  strong  tobacco — indeed,  it  may  be 
seen  in  the  pure  crystalline  state  on  the  stems.  How  much  is  due  to  the  one  or  the 
other  is  a matter  which  I have  not  attempted  to  investigate,  but  it  is  certain  that  one 
or  both  of  these  agents  play  a very  important  part  in  the  production  of  the  diseased  con- 
ditions met  with  in  the  noses  and  throats  of  smokers.  I am  fully  satisfied  that  the  throats 
and  noses  of  more  than  95  per  cent,  of  smokers  will  be  found  in  a diseased  condition, 
i.e.,  not  in  a normal  physiological  condition.  The  entire  mucous  surfaces  of  the 
pharynx  and  larynx  are  in  a chronically  hypersemic  state,  or  in  a state  of  chronic 
inflammation. 

I have  seen  great  numbers  of  smokers  with  the  epiglottis  and  true  vocal  cords  in  a 
highly  congested  state.  Many  of  those  with  congested  cords  suffer  greatly  from  a per- 
sistent hacking  cough.  Their  efforts  to  remove  the  tenacious  mucus  which  accumulates 
in  the  pharynx  and  larynx  makes  their  presence  disagreeable,  to  say  the  least  of  it. 

Throats  in  this  condition  are  always  aggravated  by  exercise,  and  particularly  by 
prolonged  speaking,  as  in  ministers  and  lawyers,  and  other  public  speakers. 

Persons  who  are  suffering  with  tobacco  throats  always  experience  much  more  diffi- 
culty in  recovering  from  acute  inflammatory  diseases  of  the  air  passages  than  other  per- 
sons thus  affected. 


DISCUSSION. 

Dr.  Stockton,  of  Chicago,  remarked,  I cannot-  agree  with  the  author  on  this 
< subject,  for  I have  found  that  chewers  suffer  more  than  smokers  do.  If  the  injuri- 
ous effects  are  due  to  the  salts  of  potash  and  the  alkaloid  nicotism,  why  do  our  laryn- 
gologists use  chlorate  of  potash  in  solution  as  a cleansing  gargle.  Potash  is  prescribed 
to  allay  congestion  of  mucous  membrane,  yet  the  worst  case  of  atrophic  rhinitis  I 
ever  saw  was  caused  by  the  use  of  potas.  chlorate.  The  cigar  smoker  does  not  get 
very  much  nicotine,  because  he  only  holds  the  smoke  in  his  mouth  for  a short  time, 
then  he  lets  it  escape,  and  the  nicotine  is  driven  off  by  the  heat  of  the  burning  leaf, 
to  some  extent.  The  cigarette  smoker  inhales  the  smoke,  so  that  it  is  taken  into  the 
system.  The  chewers,  on  the  contrary,  get  the  soluble  alkaloids,  the  saliva  being 
a very  good  solvent;  in  my  experience  the  chewer  is  the  most  severely  affected  of  the 
tobacco  users. 

Mr.  Lennox  Browne,  of  London,  bore  testimony  to  the  frequency  of  injurious 
effects  on  the  throat  from  the  use  of  tobacco,  and  was  in  the  habit  of  interdicting  it 
in  all  cases  of  obstinate  pharyngitis  occurring  in  smokers.  He  was  of  the  opinion 
that  chewing  was  more  likely  to  be  harmful  than  smoking,  and  there  was  some  evi- 
dence to  show  that  the  cigarette,  if  smoked  through  a mouth  piece,  and  if  not  inhaled 
into  the  lungs,  was  the  most  innocent  form.  The  experience  of  the  speaker  led  him 
to  believe  that  snuff  taking  was,  considering  the  proportion  of  snuff  takers,  a frequent 
factor  in  the  production  of  nasal  polypi. 

Dr.  Coomes,  in  closing  the  debate,  said  that  he  thought  Dr.  Stockton’s  remarks 
concerning  the  effects  of  the  chloride  of  sodium  were  at  variance  with  the  expe- 
rience of  every  one  who  used  that  agent  for  cleansing  the  throat  and  nose.  He 
[ considered  it  one  of  the  best  that  could  be  used.  He  had  ceased  to  use  all  of  the 


104 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


potash  salts,  save  the  bromide,  which  he  used  frequently  as  a gargle.  He  said  that 
the  mouth,  pharynx  and  nose  of  a smoker  virtually  became  a pipe  stem,  inasmuch  as 
the  smoke  came  in  contact  with  the  walls  of  these  structures,  and  were  it  not  for 
the  moisture  of  the  parts  they  would  certainly  become  covered  with  the  same  black 
mass  that  is  found  in  the  stem  of  the  pipe,  thus  affording  a full  opportunity  for  the 
absorption  of  the  nicotine. 


SECTION  XIII — LARYNGOLOGY. 


105 


FIFTH  DAY. 


Meeting  convened  at  II  A.  M.  In  the  absence  of  the  President,  Mr.  Lennox 
Browne  presided. 

On  motion  of  Dr.  Wm.  Porter,  the  following  resolution  was  passed  : — 

Resolved : That  the  President  and  Secretaries,  with  such  members  of  the  Council 
• as  have  attended  the  Congress,  be  empowered  to  decide  upon  the  publication  of  all 
papers  presented  at  the  Section. 

On  motion  of  Prof.  Ingals,  the  following  resolution  was  passed  : — 

Resolved : That  all  papers  on  our  programme  which  have  been  passed  for  future 
l consideration  be  read  by  title  and  referred  to  the  President,  Secretaries  and  members 
of  the  Council,  as  provided  by  resolution,  excepting  such  as  may  be  called  up  by  the 
Section  to  be  read  at  this  meeting. 

Prof.  Ingals  also  moved,  and  motion  seconded,  that  proof  of  all  papers  read, 
as  well  as  of  all  remarks  made  by  gentlemen  attending  the  Section  on  Laryngology  be 
furnished  to  the  authors  for  correction,  and  that  the  authors  be  given  a reasonable 
time  for  such  corrections  before  the  Transactions  are  published. 

Prof.  Ingals  moved,  motion  seconded  and  passed,  that  the  Secretaries  be 
' directed  to  publish  with  our  proceedings,  if  possible,  a list  of  the  members  who  have 
been  in  attendance. 


THE  RELATIONS  OF  PHONATION  TO  CANTATION,  WITH  SOME 

PRACTICAL  DEDUCTIONS. 

LES  RAPPORTS  DE  LA  PHONATION  AVEC  LA  CANTATION  ET  QUELQUES 

DEDUCTIONS  PRATIQUES. 

DAS  VERHALTNISS  ZWISCHEN  STIMMBILDUNG  UND  GESANG,  MIT  EINIGEN  PRAKTISCHEN 

SCHLUSSFOLGERUNGEN. 

BY  EPHRAIM  CUTTER,  M.  D. , LL.  D. , 

New  York  City. 

The  object  of  this  paper  is  to  note  some  of  the  principles  that  obtain  in  phonation 

:and  cantation,  and  to  suggest  what  may  be  of  interest  to  laryngologists  and  voice  teach- 
ers in  particular  and  the  public  in  general,  to  wit : that  as  there  is  but  little  physical 
difference  between  the  voice  in  speaking  and  the  voice  in  singing,  there  is  a pertinence 
in  proposing  that  the  rules  of  song  may,  in  some  measure,  be  applied  to  speech,  and 

Ithat  speech  may  be  more  like  music  ; agreeable  to  hearer,  easier  to  speaker,  more  intel- 
ligible and  more  effective. 

This  matter  I have  already  brought  to  the  attention  of  the  Music  Teachers’  National 


106 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Association  at  Indianapolis  this  season,  but  I feel  that  the  presentation  should  also  be 
made  to  the  specialists  who  treat  the  vocal  organs  and  who  have  the  best  mastery  of 
their  pathology,  and  because  the  voice  teachers  naturally  look  to  thi-oat  specialists  for 
support  in  acting  on  suggestions  based  on  the  physics  of  song  and  speech. 

I.  NO  VOICE  WITHOUT  A LARYNX. 

Hence  the  terms  “head,”  “chest”  and  “abdominal”  toues  are  misnomers.  If  it 
can  be  shown  that  there  are  no  chest  or  abdominal  tones,  when  the  larynx  is  disabled, 
this  proposition  is  enforced. 

Case,  to  Illustrate. — In  April,  1866,  I removed,  by  “ thyrotomy  modified”  by  dispens- 
ing with  the  usual  tracheotomy  tube,  the  voluminous  growth  I have  in  my  possession. 
Previous  to  this  the  patient  suffered  with  complete  and  continuous  aphonia,  for  about 
two  years  or  more.  After  the  operation  she  spake  and  sung,  and  continues  to  do  so,  for 
a period  of  over  twenty-one  years.  Now,  so  long  as  the  larynx  was  occupied  by  the 
tumor,  she  had  no  voice,  no  head,  no  chest  and  no  abdominal  tones.  If  the  head,  chest 
and  abdomen  were  competent  to  produce  voice  or  tone,  why  did  they  not  do  it  while  the 
larynx  was  held  by  the  tumor  ? The  fact  is  that  these  names  were  given  when  the 
state  of  knowledge  was  not  as  complete  as  at  present.  They  satisfied,  but  had  no  good 
foundation  in  the  actual  facts  in  the  case. 

This  is  not  peculiar  to  this  department  of  human  knowledge.  The  nomenclatures 
of  disease  suffer  terribly  from  the  want  of  correspondence  with  facts  in  the  case.  Names 
have  been  conferred  on  things  that  did  not  exist;  things  thought  to  be  integral,  palpable 
and  essential  parts  of  the  subject. 

As  new  light  is  shed  on  the  hidden  parts  and  they  are  displayed  in  the  bright  sun- 
light, as  in  laryngology,  erroneous  conceptions  are  dissipated  and  new  nomenclatures 
must  result. 

But  what  shall  be  said  when  the  teachers  of  the  voice  cling  to  the  state  of  knowl- 
edge that  existed  before  laryngology  ? as  is  done  by  some  to-day.  As  well  might  the 
electrician  consider  the  state  of  knowledge  complete  before  the  year  1840,  and  ignore 
the  great  advances  since  made.  It  is  humiliating  to  see  people  of  the  present  day  using 
the  lines  and  plummets  of  past  times,  that  have  been  superseded.  Indeed,  there  is,  I 
think,  more  trouble  in  the  advancement  of  the  human  race,  from  this  very  idea  of  try- 
ing to  measure  our  present  knowledge  with  the  lines  and  plummets  of  a past  and  out- 
grown age. 

So,  to  repeat:  There  is  no  voice  without  a larynx.  As  well  might  one  speak  of  the 
head  tones,  chest  tones,  or  bellows  tone  of  a church  organ.  To  be  sure  the  chest,  the 
abdomen  and  the  head  have  much  to  do  with  the  production  of  the  voice,  and  modify 
it  when  diseased,  but  there  is  no  sense  in  telling  a person  to  produce  a head  tone,  a 
chest  tone,  or  an  abdominal  tone,  when  it  has  been  shown  that  without  the  larynx  there  is 
no  voice  of  any  kind. 

Why  not  say  laryngeal  tone  ? 

II.  OFFICE  OF  THE  CHEST  AND  THE  VOICE. 

The  chest  may  be  considered  as  simply  a part  of  the  bellows  apparatus  of  the  human 
organ  of  voice.  For  good  service  it  should  be  in  good  condition.  Broken  ribs  or  spine, 
pleurisy,  pneumonitis,  dropsy,  empyema,  consumption,  asthma,  all  interfere  with  good 
voice. 

So  that  the  environments  that  dressmakers  embarrass  the  chest  with  are  bad  for  the 
voice.  It  is  wonderful  what  vocal  results  a prima  donna  will  produce  on  the  stage 
while  the  chest  is  encompassed  by  a cuirass  that  fixes  the  ribs  so  that  the  inspiration 
heaves  the  upper  and  most  immobile  part  of  the  thorax.  It  must  be  torture;  one  can- 
not but  wonder  what  could  be  done  in  the  same  circumstances  with  the  corset  left  out. 


SECTION  XIII — LARYNGOLOGY. 


107 


Professional  people,  like  doctors,  may  pride  themselves  as  to  their  position  and  influ- 
ence in  the  world,  but  let  a dressmaker  assert  herself,  and  she  will  undo  the  dicta  of 
us  all,  though  we  were  kings  or  presidents.' 

If  it  were  the  fashion  for  vocalists  to  use  the  plaster  jackets  of  Sayre  it  would  he 
better,  as  he  fixes  them  on  during  a full  inspiration  and  puts  a big  pad  over  the  stomach, 
to  make  room  for  food  eaten. 

III.  THE  ABDOMEN 

should  be  expansible  and  its  muscles  in  good  condition.  Peritonitis,  gastritis,  enteritis, 
r diarrhoea,  dysentery,  kidney,  liver  or  pancreatic  disease,  etc.,  are  bad  for  the  voice. 
The  chest  and  the  abdomen  may  be  considered  as  the  complete  human  bellows,  which 
must  be  under  control  of  the  will,  to  avoid  too  lavish  use  of  the  breath  and  to  keep  up 
a given  pressure — -just  as  the  bellows  in  a church  organ  is  weighted,  to  give  the  desired 
power  of  tone  varying  with  the  will  of  the  organ  builder.  As  a large  bellows  is  better 
than  a small  one,  so  a large  chest  and  abdomen  are  desirable  things  for  a song  or  speech. 

IV.  THE  HEAD. 

The  head  is  that  part  of  the  human  body  above  the  neck.  While  it  does  not,  of 
itself,  make  a tone  in  phonation  or  cantation,  as  has  been  supposed,  still  it  is  indis- 
pensable. 

Without  the  mouth,  the  pharynx,  the  nose,  the  ears  and  cerebral  nerve  centres, 
normal  speech  and  singing  would  not  occur.  From  what  has  been  said,  it  is  clear  that 
oripulations  modify  the  laryngeal  sounds  into  song  or  speech. 

The  pharynx  must  be  clear  and  normal,  as  shown  by  the  disastrous  effects  on  the 
voice  when  it  is  diseased  or  when  the  palate  is  cleft. 

These  results  are  direct  and  indirect.  I have  seen  cases  where  adenoid  hypertrophies 
i of  the  pharynx  caused  inability  to  sing  properly,  by  sympathy  alone,  as  far  as  I could 
l judge. 

Patients  with  tumors  of  the  pharynx  cannot  be  good  singers  or  speakers,  according 
' to  my  experience. 

The  nose,  too,  must  be  in  good  condition  for  normal  voice.  If  it  is  occluded  by 
growths,  by  deviations  of  the  turbinated  bones,  if  the  maxillary  antra  and  the  frontal 
i sinuses  are  closed  and  diseased,  there  cannot  be  normal  voice,  chiefly,  I think,  because 
i the  conformation  is  so  altered  that  the  natural  over-tones  of  the  voice  are  altered  or 
removed,  and  thus  the  timbre  is  interfered  with.  This  subject  alone  is  worth  a paper 
by  itself. 

Mme.  Luisa  Cappiani,  of  New  York  ( The  Voice,  August,  1887,  page  126),  takes 
the  ground  that  the  vomer,  ethmoid  and  turbinated  bones,  with  the  superior  maxilla, 
form  a sounding-board,  “without  which  the  tone  will  be  vulgar  and  rough,  bare 
of  sympathy  and  devoid  of  aesthetic  expression.”  This  is  a fine  idea,  and  tallies 
with  the  position  taken  here.  The  same  writer  takes  the  ground  that  the  tonsils  never 
should  be  removed  by  the  knife.  She  insists  that  “only  a portion  of  the  tonsils  should 
be  removed  by  galvano-caustic  or  astringent  applications.  ’ ’ 

A strict  diet  of  beef  has  reduced  the  tonsils,  in  my  experience.  I never  saw  any 
surgeon  cut  out  the  whole  tonsil.  I agree  with  the  lady,  if  she  would  not  make  her 
dictum  universal,  but  partial. 

The  ears  are  necessary;  for  the  congenitally  deaf  are  dumb,  as  a rule.  Again,  as 
we  have  color  blindness,  so  we  have  sound  or  tone  deafness,  wThich  teachers  of  the  voice 
find  out  to  their  sorrow  sometimes. 

The  ear  must  regulate  the  larynx,  else  how  can  one  sing  in  time  or  tune  ? 

The  cerebral  nerve  centres  join  in  the  work  of  phonation  and  cantation  with  their 
inner  consciousness,  to  indicate  what  the  soul  wants  to  communicate,  express  or  engage 
in,  by  means  of  the  organs  of  voice. 


108 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  no  more  marked  manner  are  emotions  made  manifest  than  through  the  voice  and 
in  the  universal  language  of  music.  To  show  that  the  writer  is  not  alone  in  this  posi- 
tion, he  would  refer  to  a meeting  of  the  London  Musical  Association,  held  in  1879, 
when  Herr  Emil  Belmke  gave  a lecture  on  the  mechanism  of  the  voice,  and  Mrs.  Jenny 
Lind  Goldschmidt  and  her  husband,  among  others,  were  present.  Mr.  Behnke  main- 
tained that  the  vocal  tone  came  from  the  larynx  only,  and  ridiculed  the  terms  “ chest,” 
“head”  and  “falsetto,”  as  applied  to  the  registers.  Mr.  Lennox  Browne  compli- 
mented Herr  Behnke  on  his  successful  demonstration. 

The  writer  gave  these  views  to  the  world  in  January,  1873,  six  years  before.* 


What  musical  instrument,  or  part  of  what  musical  instrument,  is  the  larynx  like? 

It  is  unique  and  unlike  any  musical  instrument,  or  part  of  a musical  instrument. 
It  is  a pipe  to  the  human  musical  instrument,  where  the  air  enters  and  leaves  by  the 
same  lumen.  The  Jewsharp  and  penny  whistle  have  this  feature,  but  they  are  in- 
capable of  the  high  musical  effects  that  come  from  the  human  larynx. 

Again,  the  vocal  cords  themselves  are  attached  in  front  to  the  angle  of  the  thyroid 
cartilage,  so  that  they  do  not  separate  anteriorly,  while  posteriorly  they  separate  widely 
during  respiration,  like  the  letter  Y,  when  the  angle  of  the  V represents  the  front 
insertion  of  the  vocal  edges  and  the  free  ends  of  the  V represent  the  arytenoid  carti- 
lages. Close  up  the  legs  of  the  Y,  and  thus  the  vocal  platform  is  made,  while  the  vibra- 
ting chink  is  almost  exactly  what  forms  the  tone  in  a cornet  by  the  use  of  both  lips. 
In  a cornet  the  edges  of  the  lips  vibrate  as  the  cords  do,  but  here  the  parallel  ceases. 
The  vocal  cords  at  their  hinder  parts  ( i . e.,  the  free  ends  of  the  Y)  are  stiffened  and 
stretched  over  projecting  horn-like  points  called  the  arytenoid  cartilages,  which  by 
coming  together,  and  stretching  backward,  through  muscular  action  controlled  by  the 
will,  approximate  the  posterior  ends  of  the  vocal  cords  and  give  the  required  tension  to 
produce  a given  note,  automatically. 

In  these  details  of  anterior  insertion  in  one  point,  posterior  insertion  of  the  right 
vocal  cord  in  the  base  of  the  right  arytenoid  cartilage  and  the  left  vocal  cord  in  the 
base  of  the  left  arytenoid  cartilage,  is  the  uniqueness  of  the  human  larynx.  There  are 
other  particulars  touched  on  here. 

The  technical  descriptions  of  the  larynx  are  so  familiar  that  there  is  no  need  here  to 
lay  them  down  again. 


lages  come  within  half  an  inch  of  each  other,  and  are  a little  stretched  to  the  front  of 
the  mirror.  In  place  of  the  cavity  of  the  larynx,  is  seen  a platform  of  pearly  white 
sheen,  stretching  across  the  larynx.  In  the  median  line,  antero-posteriorly  (the  mirror 
reverses  this),  is  a chink  running  nearly  the  whole  length  of  the  vocal  cords,  resembling 
the  opening  of  the  lips  when  a cornet  is  played — narrow. 

The  action  is  quick  as  a flash,  the  length  of  the  tone  being  governed  by  the  time 
taken  to  say  ‘ ‘Ah.  ’ ’ The  termination  of  the  sound  is  caused  by  the  sudden  withdrawal 
of  the  arytenoid  cartilages  to  the  gate  recesses  outward  and  the  resumption  of  the  open 
windpipe  by  the  sudden  withdrawal  of  the  vocal  cords’  platform  aforesaid. 


y.  THE  LABYNX. 


WHAT  IS  SEEN  IN  THE  LARYNGOSCOPE  DURING  PHONATION. 


Take  “ah,” 


Note  that  the  arytenoid  carti- 


Now,  plionate  “Ah ” 


phenomenon  occurs,  only  the 


® Boston  Journal  of  Chemistry. 


SECTION  XIII — LARYNGOLOGY. 


109 


length  of  the  longitudinal  slit  in  the  vocal  cords  platform  is  half  the  length  of  the 
“Ah.” 

The  most  striking  points  to  be  seen  are:  the  movements  of  the  arytenoid  cartilages, 
the  building  of  the  vocal  cord  platform,  its  sudden  removal,  and  the  amount  of  chink 
between  the  vocal  cords. 

No  matter  what  the  pitch  of  the  phonation,  the  same  phenomena  are  seen,  varied 
only  as  follows  : The  higher  the  voice,  the  smaller  the  chink,  and  the  lower  the  voice, 
the  larger  the  chink.  So  that  the  larger  the  larynx,  the  heavier  and  lower  the  voice. 

This  corresponds  with  what  is  observed  daily:  Men  have  lower  voices  than  women 
and  children. 

Phonation , then , in  its  laryngeal  aspect,  is  essentially  a matter  of  short  vibration  of  the 
< true  vocal  cords. 

But  I have  given  only  the  word  “Ah.”  Let  me  give  the  sentence  : “Ah,  few  shall 
part  where  many  meet,”  with  the  observer’s  eye  on  the  laryngoscope,  as  follows:  “Ah 
ew  al  at  ar  en  ey  e ” — an  unintelligible  melange  of  phonation. 

Now,  I remove  the  laryngoscope  and  say  the  same,  and  we  have  the  result,  of  which 
the  following  is  a brief  analysis: — 

The  breath  is  inhaled. 

“Ah  ” — Vocal  cords  sound  “ Ah,”  and  the  sound  is  cut  off  by  the  opening  of  the 
vocal  cords. 

“Few” — Lower  lip  closed  against  upper  teeth,  sibilant  sound  with  expiration; 
ew  sound  from  the  vocal  cords,  closure  of  the  sound  by  withdrawal  of  the  vocal  cords. 

“Shall” — “ Sh  ” through  lips  partially  opened;  a sound  from  vocal  cords,  with 
descent  of  tongue  tip  to  behind  the  lower  incisors;  “11,”  elevation  of  the  tongue  tip  to 
front  hard  palate;  mouth  opened  and  vocal  bands  cease  to  vibrate  at  the  same  instant. 

“Part” — Lips  closed;  short  expiration;  “ a ” sound  with  vocal  cords;  closure  of 
lower  jaw,  so  as  to  bring  the  anterior  third  of  tongue  against  the  hard  palate  in  front 
of  mouth;  sound  of  t by  mouth  alone,  the  tip  of  the  tongue  suddenly  leaving  the 
hard  palate  and  mouth  opening  with  forced  expiration. 

“Many” — Vocal  cords  sound  m with  mouth  closed;  lips  open  suddenly;  tip  of 
tongue  rises  to  behind  the  incisors,  and  a sudden  opening  of  the  mouth,  with  a cessa- 
tion of  the  vocal-cord  sound,  forms  the  ny. 

“Meet.” — Lips  being  closed,  the  vocal  cords  sound  me  with  sudden  opening  of  the 
lips;  t is  formed  by  a sudden  closing  of  the  lips,  while  the  tongue  tip  remains  behind 
the  front  lower  incisors,  and  the  anterior  third  of  tongue  touches  the  hard  palate  in 
I front,  followed  by  a sudden  opening  of  the  mouth  with  an  explosive  delivery  of  the 
breath. 

SINGING  OR  CANTATION. 

The  following  are  the  phenomena  occurring  while  the  same  sentence  is  sung  on  F, 
fourth  line,  bass  clef : — 


“ 

■= 

r 

t9  I® 

p" 

w u ! 

to  !— 

- L_ 

b b 

b 

L 

And  few  shall  part,  where  ma  - ny  meet. 

Breath  inhaled. 

“Ah!” — Expiration.  Vocal  cords  form  “Ah”,  which,  when  the  time  is  up,  is 
ended  by  opening  the  vocal  cords. 

“Few.” — Lower  lip  against  the  upper  teeth,  released  with  aspiration  sound ; ew-sound 
continues  during  the  half  note,  and  ceases  with  the  withdrawal  of  the  vocal  cords. 

“ Shall.” — Sibilance  with  closed  teeth;  vocal  cords  sound  sha,  at  expiration  of  the 
time  the  mouth  closes  with  the  tongue  tip  applied  to  the  hard  palate  in  front. 

“Part.” — Lips  closed;  released  with  expiration  while  the  vocal  cords  sound  alias 


110 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


r 


the  lips  open.  At  the  expiration  of  the  time  the  tongue  tip  touches  the  hard  palate  iu 
front,  and  immediately  falls  between  the  lower  incisor  teeth. 

“Where.” — Aspiration  through  open  lips  and  vocal  cords  sound  atthesame  instant; 
at  the  expiration  of  the  time  the  vocal  cords  withdraw. 

“ Many.  ” — Lips  closed  and  vocal  cords  sounding,  the  lips  open  and  the  vowel  sound 
is  formed  till  the  expiration  of  the  time  of  the  note,  when  ny  is  formed  by  the  tongue  tip 
against  the  hal'd  palate  in  front,  its  release  and  sound  of  the  vocal  cords.  The  tone 
ended  at  the  expiration  of  the  time  by  the  vocal  cords  ceasing  to  act. 

“Meet.” — Lips  closed  and  vocal  cords  sound;  lips  open;  vocal  cords  hold  on  to 
the  sound  e till  the  time  is  up,  when  the  note  is  finished  by  the  tongue  tip  touching  the 
hard  palate,  and  suddenly  dropping,  while  the  vocal  cords  stop. 

This  description  might  he  carried  to  other  sentences,  but  it  is  enough  to  show  the 
relation  of  phonation  to  cantation.  In  both  acts  the  vocal  cords  are  the  basic  source  of 
sound.  In  both  this  basic  sound  is  modified  by  the  action  of  the  mouth,  “oripula- 
tious,”  in  very  much  the  same  way.  The  great  distinction  between  them  is  that  the 
vocal  cords  in  singing  vibrate  for  a longer  time  than  speech.  To  prove  this  let  the 
same  example  be  sung  staccato.  If  sung  very  fast  and  very  short,  the  effect  is  almost 
the  same  as  in  reading.  In  this  view  the  matter  of  the  prolongation  of  the  singing 
voice,  may  be  considered  a harmonious  prolongation  of  the  vowel  sounds  of  the  words, 
while  the  oripulations  are  about  the  same.  It  must  not  be  said  that  oripulations  are 
not  sufficient  to  render  speech  visible,  for  it  is  now  a common  thing  to  see  deaf-mutes 
read  correctly  from  the  lips  and  mouth  what  is  said  by  persons  in  ordinary  conversa- 
tion. The  speakers  use  their  vocal  cords,  hut  as  the  deaf-mutes  cannot  hear  them,  it 
must  be  inferred  that  they  get  their  ideas  of  what  is  said  from  the  lips  and  mouth, 
because  I have  noticed  that  the  utterances  were  made  with  the  mouth  wider  open  than 
usual,  so  that  the  mutes  almost  see  the  uvula. 

IS  PHONATION  SUBJECT  TO  THE  SAME  LAWS  OR  LIKE  LAIVS  AS  CANTATION? 

I think  so.  Singing  differs,  as  has  been  seen,  mainly  in  the  prolongation  of  the 
basic  laryngeal  vowel  sounds.  Otherwise  they  are  alike  in  pitch  or  key,  in  timbre  or 
overtones,  in  atmospheric  air,  in  the  working  of  the  chest  and  abdominal  bellows  appa- 
ratus, to  say  no  more.  Why  then  should  there  not  be  an  application  of  some  of  the 
rules  of  harmony  to  speaking  as  is  done  to  singing  ? This  question  has  come  to  me 
during  the  preparation  of  this  paper  and  I cannot  but  ask  it  here.  Aware  that  the  late 
Professor  L.  B.  Monroe,  of  Boston,  tried  to  work  this  up,  I do  not  feel  that  I can  decide 
as  to  the  application,  still  there  can  be  no  harm  in  suggestions  made  in  the  hope  that 
those  who  are  especially  conversant  and  interested  in  this  important  subject  may,  per- 
haps, catch  a hint  which  may  lead  to  positive  results.  Surely  there  is  a need.  I have 
followed  public  speakers  with  a view  of  ascertaining  the  pitch  of  their  phonation,  and 
have  been  surprised  at  the  variations  of  tone  running  through  an  octave  at  least,  with 
none  of  the  symmetry,  order  and  harmony  of  musical  progression.  The  effectiveness 
of  such  speakers  as  compared  with  those  who  kept  their  voice  within  two  or  three  tones 
was  very  much  less.  The  glides,  or  the  inflections,  major  and  minor,  seemed  used  with- 
out any  reason.  In  the  responsive  readings  in  church,  for  example,  nearly  every  gamut 
is  heard,  but  the  effect  is  not  harmonious,  of  course.  The  voices  speak  together  but  do 
not  blend. 

Suggestion  1. — For  responses  or  reading  in  unison,  find  the  key  note  of  the  audito- 
rium. Then  have  the  congregation  read  on  the  pitches  1-3-5-8.  The  men  might  take 
one,  the  boys  three,  the  girls  five,  and  the  women  eight ; or  in  any  other  way,  pro- 
vided the  chord  is  maintained. 

Suggestion  2. — As  speaking  in  a monotone  is  more  easy  to  be  heard,  let  the  speaker 
find  out  the  key  note  of  the  auditorium,  and  if  his  own  voice  accords  let  him  adhere  to 


SECTION  XIII — LARYNGOLOGY. 


Ill 


the  pitch  ; if  not,  take  a third,  or  lifth,  or  eighth,  and  stick  to  it,  only  varying  three  or 
more  notes  as  may  he  necessary.  For  example,  take  F,  fourth  line,  bass  clef,  as  the 
pitch.  In  quotations  use  G,  fourth  space,  bass  clef.  Iu  reading  iu  a dialogue  or  paper 
where  three  persons  are  represented,  use  A,  G,  F,  employing  a different  tone  for  each 
person.  Thus  the  individuality  would  be  readily  preserved  and  could  be  clearly  dis- 
tinguished by  the  hearer  with  pleasing  effect. 

I have  other  suggestions  to  make,  but  these  are  enough  to  show  the  drift  of  thought, 
to  show  that  the  union  of  phonation  with  the  rules  of  hearing  is  not  impossible,  and  is 
likely  to  be  fraught  with  the  best  results  by  avoiding  reckless  waste  of  conflict  of 
voice  and  waves  of  sound  in  useless  changes  of  pitch ; by  making  unison  responses  really 
so  in  fact ; by  better  distinction  of  character  in  a composite  production;  by  better  hear- 
ing of  the  auditor. 

SYLLABUS  OF  THE  LARYNGOSCOPICAL  DEMONSTRATION  OF  WHICH  THIS  PAPER  IS 

A PART. 

1 . Appearance  of  my  larynx  during  respiration  only. 

2.  Appearance  during  the  act  of  laughing,  showing  both  the  false  and  true  vocal 
cords. 

3.  Appearance  during  the  holding  of  the  breath,  and  showing  the  false  vocal  cords 
forming  a closed  platform,  which  shuts  the  larynx  tight  enough  to  stop  and  hold  the 
breath. 

4.  Playing  on  the  vocal  cords  as  on  an  instrument. 

5.  Phonation  and  cantation  of  a,  e,  i,  o and  u. 

APPEARANCES  OF  LARYNX  WHEN  “ AH  ” IS  PHONATED  AND  SUNG  ON  THE  FOL- 
LOWING NOTES. 

1.  F,  first  space  below  the  staff,  bass  clef. 

2.  F,  fourth  line,  bass  clef. 

3.  F,  first  space,  treble  clef. 

4.  F,  fifth  line,  treble  clef. 


In  the  absence  of  Dr.  Camalt  Jones,  of  London,  Dr.  Stockton,  of  Chicago, 
read  bis  paper,  entitled — 

THE  ACTION  OF  THE  EPIGLOTTIS  IN  SWALLOWING. 

L’ACTION  DE  L’fSPIGLOTTE  DANS  L’AVALEMENT. 

UBER  DIE  THEILN AHME  DER  EPIGLOTTIS  AM  SCHLINGEN. 

BY  DR.  CAMALT  JONES. 

It  used  to  be  taught  that  the  epiglottis  had  an  action  like  a lid,  and  that  one  of  its 
functions  was,  in  the  act  of  swallowing,  to  shut  down  over  the  larynx,  as  if  it  were 
hinged  on  at  the  base  of  the  tongue,  and  thus  to  prevent  food,  etc. , from  passing  into 
the  larynx  ; and  that,  in  addition,  the  epiglottis  being  thus  tilted  backward  and  down- 
ward acted  as  a sort  of  guide  or  shute  for  the  food,  and  directed  it,  to  some  extent, 
toward  the  upper  end  of  the  oesophagus,  when  pushed  backward  by  the  base  of  the 
tongue. 

“ It  (the  Epiglottis)  is  placed  in  front  of  the  superior  opening  of  the  larynx,  project- 
ing, in  the  ordinary  condition,  upward,  immediately  behind  the  base  of  the  tongue,  but 


112 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


during  the  act  of  swallowing  it  is  carried  downward  and  backward  over  the  entrance 
into  the  larynx,  which  it  covers  and  protects.”  (Swain’s  “ Anatomy,”  1876,  page  283.) 

“ The  root  of  the  tongue  being  retracted  and  the  larynx  being  raised  with  the 
pharynx  and  carried  forward  under  the  tongue,  the  epiglottis  is  pressed  over  the  upper 
opening  of  the  larynx  and  the  morsel  glides  past  it,  the  closure  of  the  glottis  being 
additionally  secured  by  the  simultaneous  contraction  of  its  own  muscles,  so  that  even 
when  the  epiglottis  is  destroyed  there  is  little  danger  of  food  or  drink  passing  into  the 
larynx  so  long  as  the  muscles  can  act  freely.”  (Kirke’s  “Handbook  of  Physiology,” 
edited  by  Morrant  Baker,  1872,  page  264.) 

These  two  quotations  are  sufficient  to  prove  what  the  old  teaching  has  been,  and  I 
have  never  read  or  heard  of  any  doubt  being  cast  on  the  lid-like  action  of  the  epi- 
glottis. 

For  my  own  part  I do  not  believe  that  the  epiglottis  has  any  such  action. 

Occasionally,  with  the  laryngoscope,  an  epiglottis  may  be  seen  hanging  backward 
over  the  glottis  instead  of  “ projecting  upward  behind  the  base  of  the  tongue,”  and  so 
far  covering  the  larynx  that  it  is  impossible  to  get  a view  of  its  interior,  and  thus  sug- 
gesting that  it  would  only  have  to  go  a little  further  hack  or  to  shut  down  a little  more 
to  form  a complete  protection  to  the  larynx  against  the  entrance  of  any  foreign  body  on 
its  passage  from  the  mouth  to  the  oesophagus,  but  when  seen  in  this  position  it  also 
suggests  the  idea  that  in  vomiting  it  would  be  just  in  the  very  position  to  intercept 
material  in  its  passage  upward  and  forward,  and  to  direct  it  with  considerable  force 
into  the  larynx.  Are  we  to  suppose  that  the  epiglottis  goes  with  the  tide,  and  when 
the  stream  flows  backward  the  epiglottis  flaps  in  the  same  direction,  and  that  when  the 
stream  flows  forward  the  epiglottis  projects  toward  the  tongue?  In  any  case,  it  must 
be  remembered  that  a pendulous  epiglottis  is  not  a normal  one,  and  that  when  such 
cases  come  under  observation  it  is  generally  on  account  of  some  throat  trouble. 

I have  many  times  noticed,  when  using  a brush  to  make  an  intra-laryngeal  appli- 
cation, that  the  epiglottis  has  the  power  of  closing  the  sides  together  ; that  is  to  say, 
that  the  lateral  borders  approximate  in  the  middle  line  over  the  glottis,  and  the  front 
of  the  epiglottis  remaining  erect  it  folds  its  two  sides  together,  leaving  only  a small 
round  or  oval  opening  immediately  behind  the  tip  of  the  epiglottis.  The  epiglottis  at 
this  time  presents  an  appearance  not  unlike  an  infant’s  tongue  when  sucking  the  breast, 
and  it  is  necessary  to  wait  until  the  patient  allows  the  epiglottis  to  unfold  itself,  if  an 
application  is  to  be  made  to  the  vocal  cords,  or  the  brush  will  pass  over  the  larynx  into 
the  oesophagus. 

There  are  also  cases  where  the  epiglottis  stands  up  very  prominently  behind  the  base 
of  the  tongue,  and  can  be  seen  without  the  mirror  by  drawing  the  tongue  forward,  or 
even  only  slightly  depressing  it.  In  some  of  these  cases  the  epiglottis  can  be  seen  to 
diminish  its  breadth  by  folding  the  sides  together,  but  I have  never  seen  it  flap 
backward. 

One  simple  experiment,  which  can  be  tried  by  any  one,  also  goes  to  show  that  the 
backward  movement  of  the  base  of  the  tongue  necessary  to  allow  the  flapping  backward 
of  the  epiglottis  is  more  theoretical  than  practical. 

Take  a little  water  in  the  mouth,  protrude  the  tongue  as  far  as  possible,  then  either 
close  the  teeth  firmly  on  it  or  grasp  the  tip  with  the  fingers.  Swallow,  and  it  will  be 
found  that  the  water  passes  down  the  oesophagus  in  gulps,  with  perfect  ease,  and  does 
not  enter  the  larynx  or  cause  any  discomfort  there.  It  can  also  he  noticed  at  the  same 
time,  if  the  tongue  is  held  in  the  fingers,  that  the  tongue  makes  only  a very  slight  effort 
at  retraction,  but  the  action  of  the  constrictors  of  the  pharynx  is  very  forcibly  brought 
into  notice. 

Taking  the  results  of  this  experiment,  Kirkes’  statement  that  even  when  the  epi- 
glottis is  destroyed  there  is  little  danger  of  food  passing  into  the  larynx  so  long  as  its 


SECTION  XIII — LARYNGOLOGY. 


113 


muscles  can  act  freely,  and  the  practical  knowledge  that  in  many  cases,  when  the 
epiglottis  has  been  seen  to  be  largely  eroded,  and  yet  the  patients  have  been  able  to 
swallow  freely  both  solids  and  fluids  without  any  signs  of  choking,  the  epiglottis 
can,  in  some  cases,  be  seen  to  fold  itself  together,  and  that  it  is  not  seen  to  move  back- 
ward, I submit  that  the  action  of  the  epiglottis  in  swallowing  is  that  of  closing  its 
sides  together  above  the  glottis,  and  not  that  of  shutting  down  like  a lid. 


DISCUSSION. 

Dr.  Ingals,  of  Chicago,  wished  it  not  to  be  forgotten  that  although  there  were 
numerous  instances  in  which  the  epiglottis  had  been  in  part  or  wholly  removed,  and 
the  patients  had  subsequently  been  able  to  swallow  without  difficulty,  yet  this  fact 
proved  nothing  as  to  the  function  of  the  epiglottis.  Nature  has  great  resources;  if 
we  lose  one  hand  we  get  along  with  the  other;  and  that  a hundred  people  can  swallow 
without  an  epiglottis  in  no  sense  proves  that  in  the  remaining  millions  it  does  not 
close  the  larynx  during  deglutition.  It  was  readily  apparent  that  when  the  epiglottis 
had  been  lost,  with  the  depression  of  the  base  of  the  tongue  and  the  raising  of  the 

■ larynx  nature  might  readily  close  the  larynx,  even  without  the  presence  of  the 
epiglottis. 

Dr.  C.  Slover  Allen,  of  New  York,  mentioned  a case  where  syphilis  had 
caused  destruction  of  the  centre  of  the  epiglottis  down  to  the  base  of  the  tongue, 
leaving  the  sides  of  the  epiglottis  with  muscular  attachments  intact.  A spasm  of 
[ the  pharynx  caused  by  instruments  produced  an  approximation  and  slight  rotation 
i of  these  thin  projecting  sides  of  the  epiglottis. 

Dr.  A.  B.  Thrasher,  of  Cincinnati,  0.,  remarked — These  interesting  observa- 
- tions  appear  to  me  to  indicate  the  probable  movement  of  the  epiglottis  during  the 
act  of  spasmodic  contraction  of  the  glottis  induced  by  the  local  irritation.  It  does 
not  indicate  the  condition  of  the  epiglottis  during  the  act  of  deglutition,  when  the 
i action  of  the  larynx  is  very  different,  and  we  may  not  conclude  that  there  is  no  differ- 
; ence  in  the  movement  of  the  epiglottis  during  these  very  different  conditions,  viz. , 
• spasmodic  closure  of  the  glottis  from  irritation  and  the  physiological  act  of  deglu- 
tition. 

Dr.  Stockton,  of  Chicago,  said — I think  that  the  epiglottis  has  different  action 
at  different  ages,  as  in  the  child  I found  that  the  epiglottis  closed  down  closely.  We 

■ all  know  that  the  epiglottis  can  be  caused  to  move  backward  and  forward,  as  we  see 
in  examining  the  larynx  and  base  of  the  tongue. 


Vol.  IV— 8 


114 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Dr.  Wm.  Porter,  of  St.  Louis,  Mo.,  read  a paper,  entitled — 

I.  THREE  SUPRA-EPIGLOTTIC  BENIGN  NEOPLASMS.  II.  A NEW 
PROCEDURE  IN  THE  TREATMENT  OF  CYSTIC  GOITRE. 

I.  TROIS  NEOPLASMES  SUPRA-EPIGLOTTIQUES  BENINS.  II.  UN  PROCEDE 
NOUVEAU  DANS  LE  TRAITEMENT  DU  GOITRE  CYSTIQUE. 

I.  DREI  OBERHALB  DER  EPIGLOTTIS  BEFINDLICHE  GUTARTIGE  NEUBILDUNGEN.  II.  EIN' 
NEUES  VERFAHREN  IN  DER  BEHANDLUNG  DER  STRUMA  CYSTICA. 

BY  WM.  PORTER,  M.D., 

Of  St.  Louis,  Mo. 

I.  THREE  SUPRA-EPIGLOTTIC  BENIGN  NEOPLASMS. 

(a)  Cyst  of  the  Posterior  Pharyngeal  Wall. 

This  was  the  case  of  a poor  woman  whom  I saw  at  my  clinic.  Her  only  symptoms 
were  dysphagia  and  the  constant  irritation  of  “ something  sticking  in  her  throat.” 

A direct  examination  revealed  a cyst  of  the  mucous  membrane,  about  eight  lines  in 
diameter  and  projecting  about  six  lines  from  the  posterior  pharyngeal  wall,  a little 
below  the  level  of  the  centre  of  the  tonsils. 

With  a curved-pointed  bistoury  the  sac  was  freely  laid  open  by  cutting  from  below 
upward.  To  the  inner  surface  tr.  ferri  hydrochlor.  was  applied  and  the  patient  made 
a quick  recovery;  though  until  she  ceased  her  visits  there  was  some  thickening  at  the 
site  of  the  cyst. 

A mucous  cyst  projecting  from  the  back  of  the  epiglottis  and  partly  covering  the 
glottis,  is  recorded  by  Mr.  Durham  ( Medico-Chir . Transactions , XLVli),  also  retro- 
tracheal  gland  cysts  are  described  by  Prof.  Gruber,  which  opened  into  the  trachea. 

{h)  Papilloma  of  the  Pharynx. 

A young  married  lady,  of  good  physique,  but  very  nervous,  was  recently  brought  to 
me  on  account  of  an  incessant  cough  and  some  difficulty  of  swallowing. 

A papillary  growth  was  found,  having  its  origin  j ust  below  the  left  tonsil  but  entirely 
distinct  from  it.  The  papilloma  encroached  upon  and  hung  over  the  left  wing  of  the 
epiglottis.  It  was  as  large  as  an  ordinary  Malaga  grape,  and  had  a thick,  strong  pedicle. 

The  patient  declined  operative  interference,  but  I succeeded  in  getting  her  to  con- 
sent to  the  application  of  a destructive  agent.  Chromic  acid  was  repeatedly  applied  to 
the  pedicle,  and  in  a fortnight  the  nutrition  of  the  tumor  was  evidently  impeded,  and 
in  another  week  it  sloughed  so  nearly  off  that  it  was  easily  detached. 

The  troublesome  cough  is  almost  gone,  though  the  patient  has  some  irritation  about 
the  original  site  of  the  tumor,  but  this  is  fast  disappearing. 

Luschka  {Virchow's  Archives,  Vol.  l)  and  Sommerbrodt  {Ibid.,  Vol.  Li),  have  each 
described  cases  of  pharyngeal  papilloma,  and  Mackenzie  (“Diseases  of  the  Throat,” 
Vol.  i),  refers  to  several  cases  varying  in  size  from  a pea  to  a small  grape.  This  author 
also  refers  to  two  preparations  of  pedunculated  tumors  removed  during  life,  now  in 
the  Museum  of  the  Royal  College  of  Surgeons. 

(c)  Chondroma  of  Epiglottis. 

I will  merely  refer  to  this  case,  as  a full  account  of  it,  with  the  bibliography  to  date, 
was  published  in  the  American  Journal  of  the  Medical  Sciences,  April,  1879. 

The  patient  was  a stock  raiser,  age  forty-four.  A tumor  was  found  occupying  the 
left  margin  of  the  epiglottis,  extending  about  three  lines  into  the  normal  tissue.  It 
caused  difficulty  in  swallowing  and  some  pain  in  articulation.  It  was  easily  removed 
by  rectangular  cutting  forceps  and  the  margin  of  the  epiglottis  rapidly  healed. 

The  growth  was  a chondroma  directly  connected  with  the  epiglottidean  cartilage. 


SECTION  XIII — LARYNGOLOGY. 


115 


II.  A NEW  PROCEDURE  IN  THE  TEEATMENT  OF  CYSTIC  GOITEE. 

I believe  the  method  of  treating  cystic  goitre  herein  described  will  be  found  as  effi- 
cient and  less  objectionable  than  the  usual  one  of  injecting  the  sac,  after  evacuation,  by 
a solution  of  iodine  or  iron. 

I have  but  one  case  to  report  since  adopting  this  plan.  A gentleman,  having  a large 
cyst  of  the  thyroid  gland,  consulted  me  early  last  spring.  The  growth  greatly  inter- 
fered with  his  comfort,  the  trachea  being  pushed  far  to  the  left  of  the  median  line. 
He  objected  to  the  usual  treatment  by  injections  of  irritating  fluids,  as  I told  him  it 
would  probably  necessitate  his  being  confined  to  his  room  for  some  days. 

The  fluid  was  drawn  off  by  means  of  a trocar  and  cannula,  and  six  inches  of  catgut 
steeped  in  tr.  iodine  introduced  through  the  cannula.  The  instrument  was  then 
removed,  leaving  a little  of  the  foreign  body  projecting.  As  soon  as  there  were  symp- 
toms of  local  inflammation  the  catgut  was  removed  and  a compress  placed  over  the 
region  of  the  cyst.  There  was  very  little  annoyance  and  there  has  been  no  return  of  the 
I cyst. 

DISCUSSION. 

Dr.  E.  Fletcher  Ingals,  of  Chicago,  thought  the  treatment  new  and  believed 
it  would  be  found  of  great  value. 

Dr.  Stockton,  of  Chicago,  said  : In  my  clinic  in  Chicago,  pure  carbolic  acid  has 
; been  used  to  inject  the  cysts  with,  and  in  one  or  two  cases  very  successfully.  The 
quantity  of  acid  used  was  only  about  five  minims. 


Dr.  C.  M.  Desvernine,  of  Havana,  Cuba,  read  a paper  entitled  : — 

A CRITICAL  AND  EXPERIMENTAL  ESSAY  ON  THE  TENSION 
OF  THE  VOCAL  BANDS. 

UN  ESS  A I CRITIQUE  ET  EXPERIMENTAL  SUR  LA  TENSION  DES  CORDES 

VOCALES. 

KRITISCHE  UND  EXPEPJMENTELLE  STUDIEN  UBER  DIE  SPANNUNG  DER  STIMMBANDER. 

BY  DR.  C.  M.  DESVERNINE, 

Havana,  Cuba. 

The  earlier  investigators  on  the  mechanism  subserving  the  longitudinal  tension  of 
the  so-called  vocal  cords,  once  acquainted  with  the  distal  attachments  or  their  longi- 
i tudinal  elements,  naturally  located  the  active  force  regulating  their  distention  in  the 
muscular  apparatus  having  under  its  control  such  displacements  of  the  thyroid  and 
l"  arytenoid  insertions  which  directly  influence  their  length,  and,  as  a matter  of  course, 
the  solution  of  a problem  was  sought  in  the  study  of  the  anatomy  and  physiology  of 
' the  thyroid  and  cricoid  cartilages,  the  crico-thyroid  articulations  and  the  set  of  muscles 
: connected  therewith.  The  relative  simplicity  of  this  group  of  anatomical  elements 
I soon  afforded  a most  accurate  morphological  description,  and  their  superficial  situation 
rendered  it  exceedingly  easy  to  investigate  experimentally  the  effects  of  the  muscular 
f action  on  the  cartilaginous  organs  between  which  the  vocal  ligaments  are  stretched, 
i But  there  must  be  some  fundamental  factor  that  eludes  experimental  control,  since  the 
J results  arrived  at  by  equally  competent  observers  are  no  more  concordant,  even  now-a- 
days,  than  they  were  more  than  two  centuries  ago,  in  the  times  of  Dodart  and  de  Halle. 


116 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


There  are,  indeed,  but  few  points  on  which  the  uniformity  of  opinion  is  absolute. 

It  is  unanimously  said  and  believed  that  the  crico-thyroid  muscles  distend  the 
bands  ; but  contrasting  with  this  accord  as  to  their  functional  significance,  we  have  on 
the  explanation  of  the  accomplished  act  a sum  of  information  made  up  of  the  most 
conflicting  theories,  the  difficulties  residing  in  the  precise  determination  of  the  excur- 
sions of  the  cartilages  best  adapted  to  bring  on  aud  control  the  adequate  attitudes 
requisite  for  distinct  sonorous  tensions. 

The  current  theories  thereon  may  be  classed  in  two  main  groups. 

1.  Those  who  affirm  that  the  condition  sine  qua  non  of  the  elongation  of  the  bands 
is  the  approximation  anteriorly  of  the  cricoid  aud  thyroid  cartilages,  with  a corresponding 
depression  of  the  arytenoid  region. 

2.  Those  who  assert,  on  the  contrary,  that  the  cartilages  are  separated  or  kept  apart 
by  the  crico-thyroid  muscles. 

The  second  group  has  only  a historical  interest,  the  greatest  weight  of  evidence  being 
in  favor  of  the  first  opinion,  and  their  supporters  dissenting  solely  as  to  which  is  the 
disturbed  cartilage  in  the  accomplishment  of  the  act. 

They  are  subdivided  thus  : — 

(a)  The  cricoid  is  the  fixed  point  and  the  thyroid  rotates  forward  and  downward. 
This  is  the  classical,  widespread  theory,  and  to  it  are  attached  the  names  of  Galen,  Cas- 
serius,  Meckel,  Muller,  Turk,  Henle,  Hyrtl,  Cruveilhier,  Quain,  Gray,  Sappey,  Car- 
penter, Huxley,  Todd,  Bowman,  Schrotter,  Heath,  Kuss  et  Duval,  Beaunis,  Morel  et 
Duval,  Mackenzie,  Wagner,  Jaccoud,  Hermann,  Dieulafoy,  de  Meyer,  etc. 

( b ) The  cricoid  is  moved  on  to  the  thyroid  : Magendie,  Longet,  Cuvier,  Lauth, 
Battaille,  Fournie,  Jeleffy,  Schech,  Schmidt,  Edwards,  Elsberg,  Cohen,  Stillman, 
Hooper,  etc. 

(e)  Both  cartilages  are  brought  together  ; Vesalius,  Merkel,  Blache  and  Beclard. 

The  crico-thyroid  muscle  is  the  active  element  that  has  furnished  such  diverging 
results  through  vivisections  and  experiments  on  the  cadaver  ; but  all  these  theories  are 
necessarily  more  or  less  defective,  inasmuch  as  they  only  give  us  the  detached  and 
independent  action  of  a muscular  apparatus  without  full  attention  to  incidental  circum- 
stances which  modify  greatly  the  ultimate  static  effects  of  its  contractions.  In  fact, 
since  Winslow’s  protest  against  the  Galenic  theory  and  Ducheune’s  (de  Boulogne)  , 
brilliant  demonstrations,  it  is  a well  established  principle  in  muscular  dynamics  that, 
physiologically,  no  muscle  ever  exerts  its  mechanical  influence  independent  of  other 
forces,  either  passive  or  actively  awakened  in  associated  automatic  centres  by  the  iuitial 
purposive  impulse.  The  effects  of  these  forces  on  their  respective  subordinate  organs 
are  in  the  aggregate,  and  functionally  considered  as  to  the  end  aimed  at,  co-relative  to 
each  other  ; but  if  mechanically  studied,  they  are  found  to  be  very  often  antagonistic. 
Their  ultimate  function,  then,  is  the  resultant  of  their  combined  action  entirely  opposed 
at  times  to  the  immediate  and  direct  manifestation  of  the  activities  of  its  constituent 
elements. 

In  our  present  case,  in  no  instance  do  I see  that  the  whole  vocal  apparatus  has  been 
placed  in  conditions  natural  enough  to  bring  upon  its  solid  frame  certain  extrinsic 
forces,  active  and  passive,  of  great  moment,  aud  which,  through  the  intricate  solidarity 
of  the  laryngeal  structural  arrangement,  are  decomposed  and  utilized  so  as  to  be  brought 
to  bear  on  the  cartilaginous  support  of  the  vocal  bands  in  the  best  possible  manner  to 
render  the  kinetic  energy  of  the  crico-thyroids  most  effective  on  the  length  and  resist- 
ance of  the  bands. 

The  crico-thyroid  muscles  will  approximate  the  thyroid  to  the  cricoid,  or  the  cricoid 
to  the  thyroid,  or  both  to  each  other,  according  to  the  relative  fixity  afforded  to  its 
insertions  ; but  neither  of  these  results  can  be  in  harmony  with  the  demonstrations  of 


SECTION  XIII — LAKYNGOLOGY. 


117 


lie  laryngeal  mirror  and  clinical  observation,  because  the  experimental  basis  has  not 
ieen  as  exact  as  it  should  be. 

Ferrein,  the  first  experimenter  on  the  human  cadaver,  detaching  the  larynx  with  a 
lortion  of  the  trachea,  studied  thereon  the  effects  of  a current  of  air. 

J.  Muller  solidly  fixed  the  human  larynx  to  a board,  nailing  down  the  arytenoid 
ind  cricoid  cartilages,  and  he  succeeded  in  elevating  the  pitch  of  the  sound  produced 
ly  a current  of  air  passing  through  the  glottis,  by  tilting  forward  the  thyroid  through 
i weight  and  pulley. 

Longet,  after  sectioning  the  superior  laryngeal  nerves  in  dogs,  provoked  a hoarseness 
readily  overcome  by  approximating  anteriorly  both  cartilages. 

Hooper,  in  thoroughly  etherized  dogs,  well  secured  to  a dog-holder,  stimulated  elec- 
rrically  the  exposed  superior  laryngeal  nerves  without  disturbing  any  muscular 
ittachments.  Through  a system  of  levers  stuck  into  the  centre  of  the  thyroid  and 
\ cricoid  cartilages,  and  on  proper  stimulation,  before  and  after  section  of  the  medulla 
ablongata,  he  obtained  tracings  on  a smoked  revolving  cylinder  showing  that  the  cricoid 
was  drawn  up  to  the  thyroid. 

These  are  the  leading  data  upon  which  is  based  our  present  knowledge  of  the  physio- 
logical roZe  of  the  crico- thyroid  muscles.  They  teach  us  that  the  rotation  forward  of 
1 the  thyroid  alters  the  tension  of  the  bands,  and  also  the  simultaneous  approximation 
of  both  cartilages  to  each  other.  They  tell  us  likewise,  that  the  direct  stimulation  of 
i the  crico-thyroids  displaces  the  cricoid  because  it  is  less  solidly  fixed  than  the  thyroid, 
and  that,  on  certain  conditions  the  least  resistance  is  in  the  line  of  its  rotation  upward. 
(No  other  evidence  do  these  experiments  convey,  and  by  no  means  do  they  contain  the 
proofs  that  either  of  these  results  is  exclusively  the  constant  effect  of  the  muscular 
' power  under  consideration,  when  associated  with  the  variable  and  complex  circumstances 
attending  normal  phonation.  In  fact,  during  normal  vocalization,  the  increasing 
demand  of  tension  of  the  vocal  bands  for  a series  of  ascending  prime  tones,  coincides 
invariably  with  the  progressive  ascent  of  the  whole  larynx,  carried  up  from  its  respira- 
tory position,  by  the  powerful  supra-hyoid  muscles.  Consequently,  the  trachea  being 
put  upon  the  stretch,  the  tension  muscle  is  called  upon  to  act  with  its  insertions  under 
the  influence  of  two  antagonistic  forces  unequally  distributed  on  the  antero-posterior 
diameter  of  the  cricoid,  against  its  anterior  segment  through  the  greatest  resistance  of 
the  anterior  portion  of  the  trachea  and  the  unyielding  tracheo-cricoid  ligament  on  the 
one  side,  in  contrast  with  the  elasticity  of  the  posterior  tracheal  ligament  on  the  other. 
The  immediate  result  of  these  factors  is  a more  or  less  effective  separation  of  the 
1 cricoid  and  thyroid  cartilages  anteriorly,  limited  solely  in  this  tendency  by  the  energy 

< of  the  traction  force  and  the  elasticity  of  the  anterior  inter-cartilaginous  ligament. 

Now  then,  the  obliquity  of  the  fibres  of  the  muscle  in  question  is  a very  unfavor- 
able mechanical  disposition  for  it  to  overcome  resistances  thus  distributed,  and  the  worst 
c possible  conditions,  hindering  such  an  evolution  of  the  muscular  power,  are  created  by 
the  unsteadiness  of  the  fulcrum  as  represented  by  the  crico-thyroid  articulations.  Under 
these  conditions,  the  significance  of  the  end  points  of  the  cricroid,  as  to  motility  and 

< resistance,  are  necessarily  reversed,  and  the  form  changes  consequent  to  the  active  force, 
a being  inversely  proportional  to  the  resistances  acting  in  opposition  to  the  movement, 

the  effective  traction  force  has  to  resolve  itself,  in  this  case,  in  the  direction  of  the  crico- 
thyroid articulations,  as  representing  the  initial  absolute  motility,  and  not  in  the  line 
: tangential  to  the  arc  of  rotation  of  the  cartilage.  As  opposed  to  these  interpretations, 
i there  is  the  general  assertion  that  the  movement  allowed  by  the  crico-thyroid  joints  is 
1 of  a rotatory  description,  the  articular  surfaces  revolving  on  their  transverse  axis.  But 
* this  limitation  is  not  correct,  since  the  articular  surfaces  are  susceptible  of  a general 
I gliding  motion  impressed  upon  them  and  directed  by  the  powers  acting  on  their  levers. 

' The  geometric  sections  of  the  opposed  surfaces  and  the  lax  capsular  ligaments,  with  their 


118 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


reinforced  antero-inferior  fasciculi,  permitting  and  limiting,  respectively,  the  displace- 
ment, but  not  determining  it. 

My  own  investigations  to  determine  how  the  tension  of  the  bands  is  regulated,  rest 
exclusively  on  clinical  observation,  dissections  and  experiments  on  the  cadaver.  Vivi- 
section led  me  previously  to  certain  misinterpretations. 

The  narrow  compass  assigned  to  us  on  this  occasion  compels  me  to  omit  all  technical 
description. 

My  leading  object  has  been  to  determine  how  the  bands  are  influenced  by  different 
positions  of  the  cricoid  and  thyroid  cartilages  in  distinct  positions  of  the  larynx,  and 
to  ascertain  under  which  circumstances  the  maximum  distensive  effect  is  obtained. 

I proceeded  thus: — 

Fixing  the  thyroid  solidly  in  its  cadaveric  position  and  acting  on  the  cricoid  so  as  to 
approach  it  to  the  thyroid,  it  was  found  difficult  to  execute  the  required  rotation  with- 
out a concomitant  slipping  movement  upward  and  backward.  To  succeed  in  the 
attempt  the  traction  had  to  be  directed  forward  and  upward,  and  then  certain  results 
originated  utterly  incompatible  with  the  possibility  of  such  a rotation  ever  presiding 
by  itself  over  the  longitudinal  tension  of  the  bands — above  all,  in  the  respiratory  posi- 
tion of  the  larynx. 

Thus,  the  length  of  the  glottis  from  its  extreme  anterior  point  to  the  inter-arvtenoid 
region  measured  twenty-five  m.  before  and  after  the  experiment;  the  width  of  the 
glottis  was  not  reduced  and  the  bauds  assumed  a thick,  lax  appearance.  The  aryte- 
noids were  invariably  depressed  three  m.  at  least. 

The  cricoid  being  properly  fixed,  the  uncomplicated  rotation  of  the  thyroid  downward 
yielded  similar  results.  Repeating  the  previous  experiment,  but  allowing  the  cartilages 
to  glide  over  as  it  is  their  natural  tendency — forward  in  the  case  of  the  thyroid  and 
backward  with  the  cricoid.  Then  a certain  extension  of  the  bands  takes  place,  but 
they  remain  comparatively  lax  even  after  previous  coaptation  of  the  arytenoids. 

Now,  then,  by  the  gradual  elevation  of  the  thyroid  to  its  full  capacity,  the  crico- 
thyroid space  gainsfive  m.  in  height  over  the  six  and  a half  that  it  has  when  undisturbed; 
the  upper  surfaces  of  the  bands  are  depressed  four  m.,  and  they  become  somewhat 
resilient.  The  cricoid  is  less  movable.  Thus  prepared,  if  we  proceed  to  study  the 
problem  under  discussion,  we  learn  certain  facts  of  great  interest.  The  cricoid  being 
firmly  secured,  if  we  tilt  the  thyroid  forward  and  downward,  an  actual  distention  of 
the  bands  takes  place,  of  one  and  a half  m.  as  an  average  ; but  their  free  border  is  yet 
lax,  they  are  easily  turned  over  and  they  remain  so. 

Reversing  the  basis  of  the  experiment,  if  we  maintain  the  thyroid  absolutely 
immovable,  and  we  act  on  the  cricoid,  three  things  may  happen : — 

1.  The  cricoid  being  rotated  strictly  upward  as  far  as  possible,  then  we  have  depres- 
sion of  the  arytenoid  region,  slight  elongation  of  the  bands,  slight  diminution  of  the 
width  of  the  glottis,  vocal  bands  thick  and  lax  at  their  free  border. 

2.  The  cricoid  is  elevated  and  allowed  to  slide  backward,  then  we  obtain  elevation  of 
the  arytenoid  region,  elongation  of  the  bands  from  twenty-five  to  twenty-six  and  a half 
m. , the  width  of  the  glottis  is  greatly  reduced,  the  bands  less  thick  and  lax  than  in 
any  of  the  previous  cases. 

3.  The  cricoid  being  acted  upon  in  the  direction  of  the  fibres  of  the  crico-thyroid 
muscles,  then  it  is  readily  and  energetically  displaced  backward  and  upward,  the 
glottis  is  reduced  to  a mere  chink,  the  length  of  the  bands  increased  to  28  m.,  the  ary- 
tenoids are  elevated,  the  vocal  bands  become  narrow  and  resilient,  their  free  border  is 
held  in  place  and  the  crico-thyroid  space  is  not  lessened  in  height. 

From  this  inquiry,  we  may  conclude,  I think,  that  the  excursions  of  the  cricoid 
cartilage  are  the  most  effective  in  results  on  the  modification  of  the  bands,  and  that  they 
are  not  invariably  the  same  under  all  circumstances.  That  it  influences  in  a twofold 


SECTION  XIII — LARYNGOLOGY. 


119 


and  contrasting  manner  the  physical  properties  of  the  vocal  reed,  according  to  the 
position  of  the  organ,  regulating  thus  and  controlling  in  association  with  other  factors 
the  oscillative  phonetic  antagonism  of  their  two  dimensions. 

The  crico-thyroid  muscle,  then,  is  the  direct  longitudinal  tensor  when  in  favorable 
conditions  to  retract  the  cricoid,  and  it  is  also  a direct  factor  in  the  transverse  distention. 
Its  participation  in  the  width  of  the  bands  is  in  direct  relation  to  the  capability  allowed 
to  it  in  elevating  the  cricoid  by  the  greater  or  less  depression  of  the  whole  larynx,  the 
i thyro-arytenoidei  contracting  and  swelling  proportionately  to  furnish  the  bands  with  the 
sonorous  tension  that  they  progressively  lose  as  the  organ  descends,  and  thus,  by  the  two 
sets  of  muscles,  a continual  process  of  compensation  is  kept  up. 

This  intimate  solidarity  between  the  cricoid  and  the  vocal  bands  is  to  be  explained 
by  the  presence  of  a fibro-elastic  structural  arrangement  incompletely  described  by 
anatomists  and  not  duly  appreciated  functioually  by  physiologists  and  laryngologists. 
I refer  to  the  inferior  thyro-arytenoid  ligament.  The  best  reputed  authors  give  us  dis- 
similar descriptions  of  it. 

Fournaie,  Beclard,  Huxley  and  de  Meyer  describe  it  as  constituted  by  the  general 
sub-mucous  fibrous  investment  of  the  larynx,  adherent  to  the  thyroid  anteriorly,  to  the 
i arytenoid  posteriorly,  and  below,  to  the  inferior  border  of  the  cricoid  (Fournie,  Beclard). 

Quain,  Sappey,  Gray,  Heath,  Boekel,  Morel  et  Duval,  speak  of  it  being  the  upper 
free  border  of  the  lateral  crico-thyroid  membrane  springing  from  the  upper  border  of 
the  cricoid  according  to  Sappey,  Gray  and  Mackenzie,  and  from  the  inner  edge  of  the 
upper  border  according  to  Quain. 

Based  upon  numerous  dissections  and  transverse  sections  of  the  larynx,  we  come  to 
the  conclusion  that  the  ligament  in  question  is  not  a mere  membranous  structure.  It 
; is  a large,  thick,  fibro-elastic  pyramidal  body,  as  shown  in  the  direct  photographs  which 
i I present,  bounded  internally  by  the  sub-mucous  fibrous  investment  of  the  larynx, 
j externally,  by  a membranous  expansion  attached  to  the  outer  surface  of  the  cricoid 
I cartilage,  and  below,  by  the  cricoid  cartilage  itself.  The  base  measures  no  less  than 
five  m.  half  way  from  its  anterior  to  its  posterior  extremities,  and  from  it  spring  elegant 
and  strong  offshoots  of  fibro-elastic  tissue,  filling  up  the  space  included  between  the 
I lateral  walls,  to  ascend  to  the  apex  of  the  pyramid,  where  they  terminate  intermingled 
with  and  capped  by  the  longitudinal  thyro-arytenoid  fibres. 

This  substruction  is  both  anatomically  and  physiologically  a most  integral  part  of 
the  vowel  apparatus,  and  it  represents  in  man,  together  with  the  cricoid  cartilage  and 
1 crico-thyroid  muscles  the  highest  evolutive  adaptation  of  the  elementary  disposition 
existing  in  certain  lower  vertebrates  endowed  with  modulated  voice. 

In  the  traclieo-bronchial  syrinx  of  song  birds,  for  instance,  we  have  in  its  bare  sim- 
plicity the  scheme  of  what  is  essentially  phonogenous  in  the  human  larynx.  The  thy- 
roid and  cricoid  are  represented  by  the  ossified  inferior  segment  of  the  trachea  and 
upper  portion  of  the  bronchi.  The  vocal  bands  are  constituted  by  a thick  and  loose 

- segment  of  the  general  fibro-mucous  lining  membrane,  adherent  to  trachea  and 
■ i bronchi,  anteriorly  and  posteriorly.  During  phonation  two  sets  of  distinct  perpendicular 

- and  oblique  tracheo-bronchial  muscles,  double  in  the  mucous  membrane  and  stretch  it, 

; elevating  the  bronchial  ring  and  shifting  it  backward  under  the  steady  tracheal 
| extremity. 

This  is  fundamentally  the  mechanism  of  the  human  larynx,  where  the  vocal  bands 
being  furnished  with  a direct  transverse  tensor,  the  kinetic  energy  of  the  crico-thyroids 
is  brought  to  effect  distinct  form  changes  by  the  interchange  of  the  points  of  absolute 
motility  and  resistance  through  extrinsic  forces,  regulating  the  general  position  of  the 
vocal  organ. 

From  the  adduced  facts  and  considerations  I am  led  to  attribute  to  the  crico-thyroid 
muscles  an  active  intervention  in  both  the  longitudinal  and  transverse  dimensions  of 


120 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


the  vocal  bands.  If  the  larynx  is  in  the  respiratory  position,  then  it  draws  up  the  ante- 
rior segment  of  the  cricoid,  the  arytenoid  segment  is  depressed,  the  free  border  of  the 
bands  relaxed,  and  thus,  indirectly,  it  cooperates  with  the  thyro-arytenoideus  to  their 
transverse  distention.  If,  on  the  contrary,  the  larynx  is  more  or  less  suspended,  then 
its  contraction  is  resolved  in  a displacement  backward  and  upward  of  the  cricoid,  the 
hands  are  powerfully  elongated,  the  transverse  diameter  reduced  and  it  opposes  at  the 
free  border  of  the  hands,  through  the  thyro-arytenoid  ligament,  the  required  resistance 
to  the  impinging  blast  of  air. 

With  regard  then  to  the  vocal  hands,  I think  that  Ludwig’s  nomenclature  of  the 
laryngeal  cartilages  could  be  advantageously  modified.  Retaining  for  the  arytenoids 
the  designation  of  the  “ cartilages  of  position,”  the  thyroid  would  he  the  “cartilage 
of  suspension”  and  the  cricoid  the  “cartilage  of  distention.” 

These  interpretations  find  also  a solid  support  in  clinical  observations. 

Elsewhere,  I have  described  under  the  head  of  “ Laryngo-hyoid  ” paralysis, 
a hysteroid  paralytic  dysphonia  dependent  on  insufficient  action  of  the  elevators  of  the 
larynx.  The  vocal  organs  remain  more  or  less  in  the  respiratoiy  position,  and  the 
contractions  of  the  crico- thyroids  invariably  approximating  the  cricoid  up  on  to  the 
thyroid,  the  distention  of  the  bands  is  too  limited  to  pitch  properly  the  note  sounded. 
Under  a general  phonetic  effort,  intended  for  a high  prime-tone,  the  arytenoids  are 
depressed  and  the  free  border  of  the  bands  give  way  under  the  powerful  expiratory 
current  of  air,  the  thyro-artenoid  ligament  being  relaxed. 

The  traction  of  the  tongue  improves  the  voice,  and  in  some  instances  it  persisted 
normal  for  some  time  afterward.  This  phenomenon  would  be  ascribed  to  a psychical 
impression  modifying  favorably  the  laryngeal  disturbed  motility  and  brought  on  by  the 
technique  necessary  for  the  examination.  It  is  very  possible,  but  the  clinical  fact  is 
also  susceptible  of  another  interpretation.  Having  restored  the  voice  on  one  occasion 
by  the  mere  traction  of  the  tongue,  I thought  of  a reflex  contraction  of  the  paralytic 
muscles,  due  to  the  elongation  of  the  antagonistic  infra-hyoid  muscles,  analogous  to 
Westphal’s  paradoxical  contraction,  as  seen  in  other  regions  of  the  body,  and  well 
studied  by  Charcot  and  Richer. 

This  is  not  the  only  instance  in  which  the  alluded  phenomenon  can  be  observed. 

In  cases  of  functional  paralysis  of  the  adductors,  O.  K.  Oliver  says  that  to  restore 
motility  it  only  seems  necessary  “ to  start  the  machinery,”  and  he  advocates,  as  giving 
excellent  results,  phonation  during  inspiration  and  while  the  thyroid  is  being  com- 
pressed bi-laterally.  This  procedure  is  based  on  Wylie’s  investigations  demonstrating 
that  during  inspiration  in  these  conditions  the  cords  are  forcibly  adducted.  According 
to  us,  the  arytenoids  being  violently  rotated  inward  by  the  inspired  current  of  air,  the 
abductors  are  distended  and  reflexedly  the  motility  of  the  adductors  is  restored. 

In  conclusion : The  recorded  cases  of  inter-crico-thyroid  laryngotomy  with  a per- 
manent rigid  cannula  in  the  crico-thyroid  space  and  persistence  of  modulated  voice  are 
absolutely  contradictory  to  the  current  theories  on  the  elongation  of  the  bands. 

Reclus,  of  Paris,  reports  a case  of  this  instance  published  in  the  Gazette  Hebdomadaire,  : 
of  1880.  He  quotes  thus  on  the  condition  of  the  patie'nt’s  voice  : “Thanks  to  a val- 
vular cannula,  he  speaks  with  a pitched  and  powerful  voice  to  such  a measure  that  the 
existence  of  an  apparatus  in  the  wind  tract  might  be  ignored.”  I myself  performed 
Vicq  d’ Azyr’s  laryngotomy  on  a man  for  a supra-glottic  syphilitic  production  menacing 
life.  He  recovered  ad  integrum , and  the  emission  of  voice  was  not  interfered  with  in 
the  least  during  high  conversation  or  singing.  Vocalization  below  the  fundamental  ^ 
laryngeal  sound  was  impossible. 

BIBLIOGRAPHY. 

Forrein,  “Mom.  Acad,  do  Sc.,”  1741. 

Meckel,  J.  F.,  “ Traitc  Gfincral  d’Anatomio  Cotnpar6e,”  Paris,  1828. 


Transverse  section  of  the  right  vocal  cord,  x ‘15  diameters. 

b.  Asreruling  fibers  of  the  lliyro  arytenoid  ligament  . d.Anlero  posterior  elements  of 
v’fMnl  bands  n.  Papilla  tit  the  free  border  of  1.1  le  bands  .o'  .IV.  Sulnuucous  glands. 


[•Hverniin; 


1 I rvuii-ivi'i'Hf'  serial  Keel  ion  ol'llie  lell  human  vocal  Imnd.x  40  diamelers . 


Fig. I 


i 


oid  carl ilu go.  b.Thyro  arytenoid  ligament.  n. Inner  portion  Ibrined  by  the  submucous 
iik  f,i hkui>  . r .Outer  vvull  formed  by  fibers  hyjrmging  from  the  cricoid  carliln^e.d.  Anlero  posterior 
sol  lb/  vocal  bund  inlrrmiugled  wilh  ascending  fibers. o. Papilla  al  llie  free  border  of  the  ban  d . 

I- 1 ( i n n Miylouoifl  laleralis  and  llivro  hi  ylonoid  muscles . g.Vonlrirlr . liAenl riculur  band  . 

DnBv<»rnin*s 


I i*miisvoi\so  sorlinn  ol' l Ihm'Ij^IiI  laloia)  wall  oi  l lio  I iiimnu  larynx 
fl  v\ra.y  bol  woon  1 ho  I hypo  id  and  aryl  r?i  ic3i  ri  msoH.ions  oi  l ho  bands . x 'I'D  diamoloos. 

I ricoid  ( .irtilnjSe.  l).Th\n  oi<i  cfi.rtila^o .«  . | ,aior*al  r:riro  .'uyt.ennid  nmsi  I.  ,<|  Thvro  ; u \'l « *i u »i < l iiuikcIo  . 

I 1 1 >i**>  v ik<  ulijr  Kepi  urn  sfpnpat inpj  the  two  innsrlos .f'.  llaso  ol*  the  I hvro  mrl onoid  ligament  g.  AsrfMiding 
'I  iljivs  of  i riroid  origin  ol‘  I ho  same  ligament  li.  An!  ono-  post  or *ioi • libers  ol  I In.*  vural  bund  .doubled 


Fig.l.A 


Fig.  II 


t 1 'an s verse  serial  section  of  I he  left  lateral  wall  of  t ho  human  larynx . x 40  din  met  ors . 

a.b.c.lior^o  submucous  glands  showing  Lluit.  Coyne's  description  ol  the  same  is 
'■rot  correct  . For  the  res  L,  the  same  demonstration  ns  ol  the  previous  photograph,  (high) 

Denvernine 


Fig.  II.  A 


. UX.  I Alts'  » . IT.J  HU.. .A 

Transverse  sertion  of  the  rifjlil  lateral  wall  oClhe  1 11  ini: 1 1 1 larynx  x 40  diameters. 

Phe  s/imn  HCridion  ns  I In-  previous  one  . (KijJj.II.)  1 1 ip  miisrlcs  l>eiii£>  r*oninv(‘<1  . 


rM o id  ca.pl ihi gn . b. Thyroid  euiTilujijc  . r.d. Cavil  i«*s  occupied  hy  I ho  Icilcrul  • 1 i<  o . 1 i-vl cmiomI  and  Ihvi  n 
/U'lioiu  muscles  which  have  lie  on  removed  to  bring  mil  I ho  I liypo  nrylon.oid  ligumonl  ami.  ils  ronmvl 
1K  'vilh  1.1  ie  cricoid  . o.Thyrn  urylrnnid  ligmnonl  . e\  OITsIiooIk  HpHnjJjiiig  (iom  lh«*.  cricoid.  I!  Ascending  libers  ol 
koiti/'  structure. g.  Anter-o  po  s I oi*ior*  fibers  of*  I he  vocal  bmidK.doublrd  .li.l'ibrn  vnsnilai'  ini rrumscului*  septum 

Df’HVlM  nil  It* 


Fi£ . Ill 


I ns  verse  serial  seel  ion  of  Lite  left  lateral  wall  of  I he  human  larynx  x 50  diameters . 
a Outer  hound  ry  of  the  th.yro  arytenoid  ligament. 

Dr;  evei'ninc 


Fig.  IV. 


TBINCLAIR  i ION,  LITH  PHILA 


ImiKverse  serial  section  of  the  left  lateral  wall  ot'the  human  larynx . x 50  diameters. 

Same  demonstration  as  the  previous  one  . (Fij5 . Ill  ] 


I 


Fig.V 


* ansverse  serial  section,  of  the  left  lateral  wall  ofthe  human  larynx.  x 40  (Kamel  ers. 

i-t>.  Outer  and  inner  boundaries  ofthe  Lhyro  arytenoid,  ligament  . o . Longitudinal 
elements  ofthe  vocal  bands  near  the  processus  vocalis  of  the  arytonoid  . 

Doevornino . 


an  averse  serial  section  oil  he  loll  la  I era  I wall  of  I lie  human  larynx  x 40  diameters, 
a.  Processus  vocal  is  of  I ho  arytenoid  . 


Dosvoi'lli  !!<• 


Fig  VII. 


IruriHVprse  serial  section  of  I.  he  left  lnteral  wall  ol'llic  human  larynx,  x 40  diameters, 
i i.  Processus  vocalis  of  the  arytenoid,  b. The  Lhyro- arytenoid  ligament  springing  on  this  level 
from  the  inner  surface  of  the  cricoid  cartilage  . 

Dasvn-nine 


SECTION  XIII — LARYNGOLOGY. 


121 


Blache,  Art.  “ La'ynx,”  Vol.  xvir,  Diet.  Med.  in  30,  Paris,  1838. 

Muller,  J.,  “ Manuel  de  Physiologie,”  Paris,  1851. 

Czermak,  “ du  Laryngoscope,’7  etc.,  Paris,  1860. 

Longet,  “Traite  de  Physiologie,”  Vol.  n,  Paris,  1S61. 

Moure,  “ Laryngoscopie,”  etc.,  Paris,  1S65. 

Fournifi,  “ Physiologio  do  la  Voix,”  etc.,  Paris,  18GG. 

Du  Chcnne,  “ Physiologic  des  mouvements,”  Paris,  1867. 

Gray,  “Anatomy,”  Fifth  edition,  Philadelphia,  1870. 

Bakel,  Art.  “Larynx,”  Vol.  xx,  Diet.  Jaccoud,  Paris,  1875. 

Sappey,  “Anatomie,”  Paris,  1876. 

Brain,  part  31,  October,  1885. 

Wylie,  J.,  The  Edinh.  Med.  Jour.,  Vol.  xil,  1876. 

Quain,  “Elements  of  Anatomy,”  Eighth  edition,  New  York,  1877. 

Jaccoud,  “Pathologie  int.,”  Paris,  1877. 

Hermann,  “Elements  of  Human  Physiology,”  Second  edition,  London,  1878. 

Huxley,  “The  Anatomy  of  Vertebrated  Animals,”  London,  1S80. 

Dieulafoy,  “Man.  Pathol.  Ynt.,”  Paris,  18S0. 

Heath,  “ Practical  Anatomy,”  Philadelphia,  1881. 

Reclus,  “Clinique  et  critique  chirurgicales,”  Paris,  18S4. 

Klein,  et  Vairot,  “ Ilistologie,”  Paris,  1885. 

Am.  Journal  of  Med.  Ses.,  New  series,  1885. 

Desvernine,  “ De  contraccion  paradojica  deWestphal  in  laryngo  dinamica,”  Cronico-Medico- 
.uirurgica  de  la  Habana,  1886. 

See  an  abstract  of  this  paper  published  in  the  January  number  of  the  Journal  of  Laryngology, 
dited  by  Mackenzie  and  Wolfenden. 

De  Meyer,  “ Les  organes  de  la  Parole.”  Biblio.  Sc.  international,  1SS5. 


INTUBATION  OF  THE  LARYNX. 

INTUBATION  DU  LARYNX. 

UBER  INTUBATION  DES  LARYNX. 

BY  DR.  JOSEPH  O’ DWYER. 

New  York. 

Had  intubation  of  the  larynx  proved  a complete  failure  in  the  treatment  of  croup, 
should  still  feel  amply  repaid  for  the  time  and  expense  consumed  in  developing  it, 
or  I believe  that  it  offers  the  most  rational  and  practical  method  yet  devised  for  the 
elief  of  chronic  stricture  of  the  glottis. 

I have  records  of  five  such  cases  treated  by  intubation,  three  of  them  by  myself  and 
wo  by  other  physicians. 

Of  the  first  case  I will  give  only  an  abstract,  as  it  has  already  been  published  in  the 
Medical  Record  of  J une  5th,  1886.  This  patient  was  a woman  forty  years  of  age,  who 
( :ame  under  my  treatment  December  5th,  1885.  Twelve  years  previous  to  this  time  she 
lad  contracted  syphilis,  which  manifested  itself  chiefly  by  ulcerations  in  the  pharynx, 
tnd  for  the  last  two  years  had  also  involved  the  larynx,  but  without  producing  any 
Lerious  interference  with  respiration  until  within  two  months.  The  immediate  per- 
' ormance  of  tracheotomy  had  been  recommended  by  a leading  laryngologist  a short 
Rime  before  I saw  her.  The  soft  palate  was  adherent  to  the  posterior  wall  of  the 
pharynx  on  both  sides,  and  a small  ulcer  still  existed  on  the  left  side.  A cicatricial 
. land  encircled  the  left  half  of  the  larynx  and  crossed  to  the  right  over  the  posterior 


122 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


portion  of  the  chink,  leaving  only  a small  breathing  space  between  it  and  the  right 
cord.  The  epiglottis  was  also  deformed  on  its  posterior  surface  by  cicatricial  contrac- 
tion. 

On  the  date  above  given  I attempted  to  insert  the  smallest  tube  I then  had  for  adult 
cases,  but  failed  after  several  attempts,  and  was  obliged  to  fall  back  on  the  largest  of 
the  croup  tubes,  that  intended  for  children  from  eight  to  twelve  years  of  age,  which 
I succeeded  in  passing  by  using  a great  deal  of  force.  She  could  breathe  through 
this  small  tube  with  perfect  comfort  in  a state  of  rest,  and  with  it  obtained  her 
first  night’s  comfortable  sleep  in  the  recumbent  posture  in  two  months.  Tubes  of 
larger  size  were  used  in  rapid  succession,  as  the  smaller  ones  were  coughed  out,  and  she 
returned  home  at  the  end  of  eighteen  days  with  ample  breathing  room  in  the  larynx. 
During  this  time  the  tubes  were  inserted  nine  times  and  retained  an  aggregate  of  173 
hours.  She  reported  occasionally  for  observation,  and  while  there  was  no  return  of  the 
cicatricial  band,  which  had  disappeared  apparently  by  ulceration,  and  there  was  ample 
breathing  room  in  the  chink  of  the  glottis,  there  was  a gradual  return  of  the  dyspnoea, 
due,  undoubtedly,  to  sub-glottic  obstruction.  Almost  from  the  beginning  I was  con- 
vinced that  there  was  considerable  thickening  on  the  right  side  below  the  cords,  from 
the  fact  that  the  lower  extremity  of  the  tube  was  deflected  sharply  to  the  patient's  left 
as  it  passed  below  the  rima,  and  also  because  the  force  required  to  overcome  the  resist- 
ance was  greater  than  could  be  offered  by  the  cicatricial  tissue  in  the  glottis. 

After  an  interval  of  about  two  and  a half  months  I was  obliged  to  resort  to  dilata- 
tion again,  and  found  it  necessary  to  begin  with  the  smallest  tube  and  use  almost  as 
much  force  as  on  the  first  occasion,  although  there  was  veiy  1 ittle  recontraction  in  the 
glottis. 

This  time  the  patient  was  under  treatment  twenty-seven  days,  and  I used  still 
larger  tubes,  which  were  inserted  thirteen  times  and  retained  204  hours. 

I was  now  thoroughly  convinced  that  the  only  means  of  preventing  a return  of  the 
stricture  was  continuing  dilatation  by  the  occasional  introduction  of  a tube.  I,  there- 
fore, began  by  using  it  once  a week,  leaving  it  in  the  larynx  from  twelve  to  twenty-four 
hours  at  a time.  The  interval  was  gradually  lengthened  until  it  amounted  to  six 
weeks,  but  I found  that  this  was  too  long,  aud  was  obliged  to  reduce  it  to  one  month 
and  sometimes  five  weeks.  I still  continue  to  insert  this  hard  rubber  tube,  which  is 
the  largest  I have  used,  once  a month,  and  leave  it  in  from  two  to  three  days. 

It  is  now  one  year  and  nine  months  since  I began  the  dilatation  of  this  patient’s 
larynx,  and  there  is  scarcely  any  doubt  that  it  will  be  necessary  to  continue  it  during 
the  rest  of  her  life.  I am,  therefore,  beginning  to  teach  her  to  insert  the  tube  herself, 
which  I do  not  think  will  be  very  difficult,  as  she  possesses  au  uuusual  amount  of 
pluck. 

If  this  patient  omits  her  iodide,  of  which  she  was  taking  sixtj'  grains  daily  when 
she  came  to  me  and  which  I increased  to  ninety,  for  any  length  of  time,  points  of  ulcer- 
ation appear  in  the  larynx  and  on  the  posterior  wall  of  the  pharynx.  The  metal  tube 
always  produced  some  ulceration  where  it  exerted  the  most  pressure,  especially  on  the 
anterior  surface  of  the  arytenoids,  but  this  has  not  occurred  to  any  extent  with  the  light 
vulcanite  tube.  I have  used  the  latter  several  times  in  this  case,  and  while  the  patient 
doos  not  swallow  nearly  as  well  with  it  as  with  the  metallic  tube,  she  is  convinced  that 
it  causes  less  irritation,  and  that  expectoration  of  the  tenacious  mucus  is  much  easier. 
Although  swallowing  of  both  solids  and  liquids  was  very  imperfect,  this  patient  found 
no  difficulty  in  taking  an  ample  supply  of  nourishment.  Liquids  were  swallowed 
better  while  she  was  lying  on  the  back. 

Notwithstanding  the  free  use  of  cocaine,  very  sharp  pain  was  complained  of  just 
after  the  introduction  of  the  tube,  which  usually  required  a hypodermic  injection  of  mor- 
phia for  its  relief.  Tolerance  was  soon  established  aud  a repetition  of  the  dose  was 


SECTION  XIII — LARYNGOLOGY. 


123 


seldom  required  unless  tlie  tube  was  allowed  to  remain  in  the  larynx  for  about  a week, 
when  the  pain  would  again  become  severe. 

In  order  to  render  possible  the  introduction  of  the  small  tubes  used  in  the  early 
treatment  of  this  case  it  was  necessary  to  reduce  the  retaining  swell  to  almost  nothing, 
which  rendered  their  rejection  certain  as  soon  as  the  stricture  became  somewhat  relaxed. 
They  were  consequently  often  expelled  in  less  than  twelve  hours.  To  avoid  the  pain 
and  irritation  necessarily  produced  by  the  frequent  forcing  of  a tube  through  the  larynx, 
I would,  in  another  case,  if  reasonably  certain  that  the  stricture  were  confined  to  the 
ti  chink  of  the  glottis,  produce  sufficient  divulsion  under  ether  to  admit  a large  or 
medium-sized  tube  that  would  be  retained  as  long  as  desired — a week,  a month,  or 
longer,  according  to  the  pain  and  irritation  excited.  It  would  be  a much  more  rapid 
and  less  painful  method.  In  this  case  it  would  have  accomplished  nothing,  as  no 
amount  of  divulsion  short  of  rupturing  the  cricoid  cartilage  could  effect  the  sub-glottic 
stenosis. 

I have  here  a set  of  ten  laryngeal  stricture  tubes  made  by  Tiemann  & Co.,  of  New 
York.  The  retaining  swell  is  left  greater  on  the  smaller  sizes  than  it  was  on  those  used 
in  the  case  just  reported,  because  I believe  the  force  required  to  pass  the  tubes  was 
necessitated  in  great  measure  by  the  fact  that  the  sub-glottic  thickening  was  confined 
principally  to  one  side,  thus  rendering  the  canal  tortuous. 

The  larger  of  these  tubes  is  constructed  of  hard  rubber,  the  medium  sizes  of  metal, 
brass,  gold-plated,  with  vulcanite  heads  to  diminish  the  weight,  and  the  smaller  of  metal 
only.  The  heads  of  the  latter  are  left  comparatively  small,  so  that  they  can  also  be 
. used  in  acute  stenosis  of  the  larynx  in  the  years  immediately  following  puberty,  for  which 
no  provision  has  been  made  in  the  set  of  croup  instruments. 

The  largest  of  them,  in  which  the  transverse  diameter  of  the  head  is  seven-eighths 
of  an  inch,  can  be  used  in  any  form  of  acute  stenosis  in  the  large  adult  male  and  the 
medium  sizes  in  the  female  and  small  adult  male. 

In  the  largest  larynx  that  I have  yet  measured,  the  antero-posterior  diameter  of  the 
I chink,  which  is  the  same  as  that  of  the  trachea,  was  only  seven-eighths  of  an  inch,  and 
the  transverse  a little  more  than  five-eighths. 

The  diameter  of  the  sub-glottic  division  of  the  larynx  varies  from  one-eighth  to 
‘ three-sixteenths  of  an  inch  less  than  that  of  the  trachea. 

Case  ii. — Louise  M.,  aged  thirty-five,  married,  was  sent  to  me  in  April,  1886,  by  Dr. 
J.  J.  Reid,  from  the  throat  wards  of  Charity  Hospital,  where  she  had  remained  since 
the  performance  of  tracheotomy  two  years  before.  For  seven  months  of  this  time  she 
was  under  the  care  of  the  late  Dr.  ELsberg,  and  came  to  me  with  the  diagnosis  of  incur- 
able bilateral  paralysis  of  the  abductor  muscles  of  the  cords.  Electricity  and  other 
methods  of  treatment  had  been  tried  in  vain  and  her  case  was  regarded  as  hopeless  as 
far  as  the  functions  of  the  larynx  were  concerned. 

The  history  that  I obtained  as  to  the  beginning  of  her  ailment,  and  which  I do  not 
consider  reliable,  is  as  follows  : — 

During  one  of  her  periodical  sprees  with  a number  of  boon  companions  who  were 
trying  to  make  as  much  noise  as  possible  by  singing  or  screaming,  in  a desperate  effort 
to  outdo  the  rest,  she  suddenly  lost  her  voice.  Her  throat  swelled,  and  she  soon  began 
to  suffer  from  dyspnoea  and  was  ordered  to  hospital  by  a physician  who  was  called  to 
attend  her.  She  had  no  recollection  of  reaching  the  hospital  or  of  the  tracheotomy  that 
followed,  and  I could  form  no  estimate  of  the  time  intervening  between  the  first  symp- 
toms and  the  operation  ; she  placed  it  at  a few  days. 

The  introduction  of  a laryngeal  tube  with  the  vocal  bands  lying  in  apposition  and 
their  abductor  muscles  incurably  paralyzed  I regarded  as  useless,  and  did  not  contem- 
plate it  for  a moment.  My  intention  was  first  to  remove  the  vocal  cords  or  a portion 


124 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


of  them,  and  make  a cylindrical  opening  where  before  there  was  none,  and  then  insert 
a tube  until  the  healing  process  was  accomplished. 

When  I came  to  investigate  the  case  I found  there  was  not  the  least  power  to 
whisper.  She  was  obliged  to  communicate  her  thoughts  altogether  in  writing.  I 
already  knew  from  my  experience  with  intubation  in  children,  that  with  a very  small 
column  of  air  passing  through  the  larynx  the  ability  to  whisper  distinctly  is  retained. 

I found  further,  that  no  air  could  be  driven  through  the  larynx  by  stopping  the 
tracheal  cannula  and  directing  the  patient  to  make  a forced  expiration,  and  was  led  to 
the  only  conclusion  that  could  be  drawn  from  these  facts,  viz. : that  the  larynx  was 
completely  occluded,  or  that  if  any  opening  existed  it  was  a mere  pin-hole. 

In  the  mirror  the  vocal  cords  could  be  seen  closely  approximated  but  normal  in 
appearance.  No  adhesions  were  visible,  and  during  all  attempts  at  phonation  or  inspi- 
ration the  arytenoids  remained  motionless.  I now  interpreted  the  case  differently.  This 
patient  had  undoubted  symptoms  of  syphilis  when  I first  saw  her,  which  soon  disap- 
peared under  the  influence  of  the  iodide.  I believed  that  the  first  trouble  was  an  acute 
laryngitis  aggravated  by  the  constitutional  disease  and  attended  with  marked  swelling 
of  the  mucous  membrane  and  submucous  tissues,  which  brought  the  under  surfaces  of 
the  vocal  cords  in  contact. 

This  would  be  still  further  increased  by  the  cessation  of  all  attempts  at  abduction 
by  the  admission  of  air  through  the  tracheal  cannula,  and  all  that  was  required  to  seal 
the  opposing  surfaces  was  a little  ulceration  followed  by  healing. 

This  view  of  the  case  rendered  the  prognosis  much  more  favorable.  All  that  appeared 
to  be  necessary  was  to  break  up  the  adhesions  and  insert  a tube  to  prevent  reunion. 

For  this  purpose  I had  her  removed  to  the  New  York  Foundling  Asylum,  and  on 
April  29th,  1886,  assisted  by  Dr.  Dillon  Brown,  the  resident  physician,  Drs.  J.  J.  Reid, 
W.  K.  Simpson,  J.  J.  Griffiths  and  F.  S.  Sellew,  I placed  her  under  ether  and  attempted 
to  pass  a small  tube  through  the  larynx,  but  failed  after  using  a great  deal  of  force.  I 
then  enlarged  the  external  opening  and  realized  for  the  first  time  that  the  cannula  had 
been  inserted,  not,  as  I supposed,  in  the  trachea,  but  in  the  crico-thyroid  space.  No 
opening  could  be  felt  by  pressing  the  finger  upward  in  the  wound,  nor  could  any  be 
made  out  in  the  chink  of  the  glottis,  which  was  easily  reached  by  pushing  the  larynx 
up  on  the  outside  at  the  same  time  that  the  finger  was  inserted  through  the  mouth.  All 
the  force  that  could  be  exerted  in  this  manner  made  no  impression  on  the  adhesions.  I 
therefore  passed  a uterine  sound,  with  proper  curve,  guided  by  the  finger,  between  the 
cords,  and  forced  it  down  and  out  through  the  wound,  working  it  backward  and  for- 
ward, then  passed  it  in  the  same  way  from  below  upward,  and  again  tried  the  finger  iu 
both  directions,  but  failed  as  before.  A strong  pair  of  forceps  was  now  introduced, 
closed,  from  below,  opened  wddely  and  withdrawn  in  this  condition.  This  gave  room 
to  admit  the  tip  of  the  index  finger,  and  by  using  much  force,  the  adhesions  suddenly 
gave  way,  allowing  the  finger  to  pass  up  into  the  pharynx. 

I now  inserted  a tube  two  and  one-half  inches  in  length,  the  longest  I had  at  the 
time,  but  here  encountered  a difficulty  which  I had  not  anticipated.  The  lower  end  of 
the  tube  came  out  through  the  wound  and  no  means  that  I could  devise  would  keep  it 
in  place.  I was  therefore  obliged  to  reinsert  the  tracheal  cannula  until  a tube  three 
inches  long  could  be  made. 

Nine  days  later  it  was  necessary  to  etherize  the  patient  again  in  order  to  break  up 
the  adhesions,  which  had  re-formed,  before  I could  pass  the  long  tube.  "While  doing 
this,  an  assistant  drew  forward  the  inferior  angle  of  the  wound  with  a blunt  hook  and 
pressed  the  lower  end  of  the  tube  backward  as  it  passed  the  opening,  by  means  of  a lead 
pencil,  notched  at  the  end  to  prevent  it  from  slipping. 

The  increase  of  half  an  inch  to  the  length  of  the  tube  removed  the  difficulty  experi- 


SECTION  XIII — LARYNGOLOGY. 


125 


;nced  with  the  shorter  one.  A cork  was  now  placed  in  the  external  opening  and 
retained  by  a tape  passed  through  it  and  tied  around  the  neck,  which  the  patient  could 
remove  quickly  if  necessary. 

To  provide  against  the  danger  of  the  lower  end  of  the  tube  still  engaging  in  the 
ivouud  and  thus  obstructing  both  openings,  the  string  was  left  attached  to  it  and  was 
i passed  behind  the  ear. 

The  tact  that  this  patient  could  again  breathe  through  the  natural  passages  and  com- 
aiunicate  her  thoughts  in  a very  distinct  whisper  did  not  surprise  her  nearly  as  much 
is  the  ability  to  expectorate  through  the  mouth,  which  was  a great  source  of  pleasure 
md  amusement  to  her. 

The  tube  was  coughed  out  on  the  second  day,  notwithstanding  its  weight  of  one 
ounce  and  three-quarters.  The  patient  choked  immediately  and  was  obliged  to  remove 
the  cork  and  have  the  nurse  re-insert  the  tracheal  cannula.  I replaced  the  tube  in  the 
larynx  four  hours  later,  without  difficulty,  and  a week  later  removed  it  to  see  if  she 
’ could  get  any  air  at  all  through  the  larynx,  but,  to  all  appearances,  not  a particle 
entered,  and  the  tracheal  cannula  again  had  to  be  used.  A laryngoscopic  examination 
showed  the  vocal  cords  in  the  old  position  of  close  adduction.  I was  now  forced  to  the 
conclusion  that  the  original  diagnosis  of  paralysis  was  correct,  and  that  adhesion 
resulted  from  ulceration  produced  by  the  tracheal  cannula,  which  subsequently  healed 
under  anti-syphilitic  treatment. 

Ether  was  again  administered  May  20th,  1886,  and  an  operation  was  undertaken  for 
the  purpose  of  removing  a portion  of  the  vocal  cords  as  originally  intended.  I enlarged 
the  wound  downward  in  order  to  make  room  to  keep  the  cannula  in  position  during  the 
, operation,  and  at  the  same  time  to  keep  it  out  of  the  way,  and  tamponed  the  trachea 
around  it  to  prevent  any  blood  gaining  admission  to  the  bronchi.  The  incision  was 
then  carried  up  to,  but  not  interfering  with,  the  thyroid  cartilage.  On  separating  the 
edges  of  the  wound  with  retractors,  I missed  the  cricoid  cartilage,  or  at  least  the  ante- 
: rior  part  of  it.  From  the  first  ring  of  the  trachea  to  the  thyroid  cartilage  there  was  no 
' support  for  the  soft,  yielding  tissues,  and  when  the  flaps  were  allowed  to  drop  back  into 
position  the  anterior  and  posterior  walls  approximated  in  the  same  manner  as  those  of 
the  oesophagus  or  vagina.  I hesitated  now  about  proceeding  further  with  the  operation, 
as  I regarded  the  case  as  next  to  hopeless,  but  believing  that  the  cricoid  cartilage  might 
have  been  cut  in  the  original  operation,  and  only  displaced  by  the  cannula,  which  was  of 
hard  rubber  and  very  large  size,  I decided  to  complete  the  operation  by  hooking  a 
tenaculum  into  each  cord,  guided  by  the  finger,  and  cutting  on  the  outside  of  this  with 
a blunt-pointed  bistoury.  I found  this  much  more  difficult  than  I anticipated,  for  the 
cords,  although  not  far  above  the  external  wound,  were  not  visible.  In  doing  this 
operation  again,  I would  lay  open  the  thyroid  cartilage,  which  would  make  it  a very 
simple  matter. 

The  wound  was  brought  together,  with  the  exception  of  the  opening  for  the  tracheal 
cannula,  in  which  a cork  was  placed,  as  before,  and  the  same  tube  was  passed  into  the 
larynx.  At  the  end  of  eight  days  I removed  it,  and  found  that  she  could  breathe,  for 
the  first  time,  through  the  larynx,  with  the  external  wound  closed  by  adhesive  plaster. 
A laryngoscopic  examination  showed  that  only  a small  portion  of  each  cord  had  been 
i removed,  and  from  the  seat  of  the  incisions  granulations  were  already  springing  which 
t promised  soon  to  supply  the  place  of  the  tissue  removed.  I therefore  re-inserted  the 
; tube  in  the  larynx  one  day  and  a half  after  its  removal,  during  which  respiration  was 
carried  on  comfortably  through  the  natural  passages. 

More  lateral  pressure  appeared  to  me  to  be  the  thing  required  to  prevent  the  further 
' growth  of  granulation  tissue,  and  this  could  not  bo  obtained  with  the  ordinary  oval 
• tube,  which  was  designed  specially  to  avoid  undue  pressure  on  the  vocal  cords.  I 
1 therefore  had  one  made  almost  cylindrical  in  form,  and  passed  it  into  the  larynx  June 


12G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


15th,  -where  I allowed  it  to  remain  until  the  26th,  eleven  days.  I then  removed  it,  not 
because  it  was  giving  rise  to  pain  or  inconvenience  in  any  way,  but  because  my  experi- 
ence with  the  first  case  was  against  leaving  the  tube  in  the  larynx  continuously  for 
much  longer  than  a week.  On  laryngoscopic  examination,  more  breathing  room  was 
found  than  at  any  previous  time,  but  granulations  were  still  present.  During  the 
following  three  days  she  continued  to  breathe  comfortably  through  the  larynx,  with 
moderate  exercise,  aud  could  even  ascend  one  flight  of  stairs  without  producing  much 
dyspnoea. 

On  examining  the  external  opening  on  June  29th,  I noticed  a marked  sinking  in  of 
the  tissues  both  above  and  below  it,  where  the  cartilaginous  support  was  defective,  and 
I anticipated  some  difficulty  in  replacing  the  tube.  So  great  was  the  contraction  in  this 
short  space  of  time  that  on  using  a great  deal  of  force  I failed  to  pass  the  tube  beyond 
this  point  until  a slight  incision  was  made  downward. 

The  almost  certain  recurrence  of  this  difficulty  every  time  the  tube  was  allowed  to 
remain  out  for  a few  days  convinced  me  of  the  necessity  of  leaving  it  in  for  a much 
longer  time. 

I therefore  sent  her  back  to  Charity  Hospital,  with  the  tube  in  the  larynx,  and  told 
her  to  return  in  a month,  when  I would  remove  it,  or  sooner,  in  case  it  gave  rise  to 
much  pain  or  any  interference  with  respiration  occurred. 

Dr.  Reid,  in  whose  service  she  was,  reported  from  time  to  time  that  she  was  doing 
well,  and  at  the  end  of  the  month  reminded  her  that  it  was  time  to  have  the  tube 
removed.  She  left  the  hospital,  but  did  not  report  to  me,  and  months  passed  without 
healing  anything  from  her.  Knowing  that  she  was  much  given  to  dissipation,  I 
believed  that  in  all  probability  she  was  dead;  but  she  surprised  me  very  much  by 
coming  to  my  office  on  May  3d  last,  looking  and  feeling  remarkably  well,  with  the 
exception  of  a cold  recently  contracted,  which  gave  rise  to  a good  deal  of  cough.  She 
was  still  wearing  the  tube,  which  had  remained  in  the  larynx  ten  months  and  four 
days.  Her  reason  for  not  returning  sooner  was  that  she  felt  comfortable  and  happy 
and  did  not  wish  to  run  the  risk  of  having  to  wear  the  outside  tube  again. 

It  required  some  force  to  remove  the  tube,  which  was  black,  from  coating  of  the 
sulphides,  and  closely  dotted  over  with  coarse  granules  of  calcareous  matter.  When 
these  were  scraped  off,  the  surface  of  the  metal  was  left  quite  uneven,  and  the  tube  is, 
consequently,  somewhat  smaller  now  than  it  was  originally.  The  thin  gold  plating 
had  probably  disappeared  before  the  tube  was  in  the  larynx  a month. 

For  a moment  after  the  tube  was  removed  inspiration  was  seriously  obstructed,  and 
I was  about  to  insert  another  one,  which  I had  ready,  when  the  breathing  became  per- 
fectly free.  On  using  the  mirror  I found  that  the  obstruction  was  due  to  masses  of 
granulation  tissue  growing  from  the  sides  of  the  larynx  above  the  ventricular  bands, 
which  must  have  partially  overlapped  the  head  of  the  tube,  and  which  were  drawn 
together  by  the  forced  inspiration  immediately  following  the  removal  of  the  tube. 
During  quiet  respiration  this  did  not  occur.  A good  view  of  the  larynx  could  not  be 
obtained,  and  if  ulceration  existed,  which  is  more  than  probable,  it  was  covered  by  the 
granulation  tissue. 

She  complained  for  some  days  of  a void  in  her  throat,  as  if  an  important  part  of  it 
were  missing. 

The  granulations,  which  I believed  at  first  would  have  to  be  removed,  in  some 
manner  gradually  decreased  in  size,  and  at  the  last  examination,  about  July  1st,  a 
better  view  of  the  larynx  was  obtained.  A large  cylindrical  opening  existed  where 
the  chink  should  be,  and  no  trace  of  the  vocal  cords  was  visible.  There  was  undoubted 
motion  of  the  arytenoids  during  inspiration.  In  the  seat  of  the  external  wound  was  a 
deep  sulcus  extending  down  between  the  unapproximated  edges  of  the  cricoid  cartilage. 
The  cough  was  toneless,  and  the  voice,  as  before,  a distinct  whisper. 


SECTION  XIII — LARYNGOLOGY. 


127 


I have  not  seen  this  patient  since,  but  Dr.  Reid  informed  me  that  she  returned  to 
Charity  Hospital  in  the  early  part  of  last  August,  suffering  from  alcoholism,  and  left  in 
about  a week.  He  examined  the  larynx  and  found  the  same  condition  as  described 
above.  The  breathing  was  perfectly  free. 

Had  I the  least  suspicion  that  the  larynx  would  tolerate  a tube  continuously  for  so 
long  a time  I would  not  have  interfered  with  the  vocal  cords,  as  the  tube,  if  it  did  not 
cause  their  destruction  by  ulceration,  would  in  all  probability  have  fixed  them  perma- 
nently in  the  abducted  position.  I felt  that  I was  assuming  a serious  responsibility 
when  I concluded  to  leave  the  tube  in  the  larynx  for  even  the  space  of  one  month. 

These  two  cases  afford  a remarkable  illustration  of  the  difference  in  sensibility  dis- 
played by  the  larynx  in  different  persons.  One  could  not  retain  a gold-plated  or  finely 
polished  vulcanite  tube  longer  than  a week  at  a time  without  its  producing  undue  irrita- 
tion, while  the  other  practically  wore  a hollow  file  and  not  a very  fine  one  either,  in 
her  larynx  for  many  months,  and  was  happy  in  consequence. 

I had  previously  noticed  the  same  difference  in  children  suffering  from  croup,  and 
at  first  attributed  it  to  the  protection  afforded  to  the  living  sensitive  tissues  by  a greater 
or  less  deposit  of  pseudo-membrane,  but  was  soon  convinced  that  this  was  not  the 
explanation. 

Case  hi. — Mrs.  L.,  aged  40,  the  mother  of  eight  children,  in  the  early  part  of 
December,  1886,  began  to  suffer  from  hoarseness  and  a feeling  as  though  something 
loose  existed  in  the  upper  part  of  the  windpipe,  which  she  could  not  get  rid  of  by 
: coughing.  She  consulted  Dr.  J.  W.  Lyman  who  found  bronchitis  and  albuminuria  and 
these  together  with  the  hoarseness  were  believed  to  be  due  to  cold.  Later  the  voice 
was  lost  and  dyspnoea  developed.  The  latter  became  so  urgent  on  the  night  of  January 
14th,  1887,  that  everything  was  made  ready  for  tracheotomy,  when  it  occurred  to  Dr. 
H.  Griswold,  who  was  called  in  consultation,  that  it  would  be  a good  case  for  intubation. 
When  I saw  her,  at  9 P.M.,  there  was  very  little  cyanosis  but  the  breathing  was  very 
laborious,  but  almost  noiseless.  She  was  unable  to  assume  the  recumbent  posture.  Dr. 

; Griswold  had  made  a satisfactory  laryngoscopic  examination  and  found  nothing  abnor- 
mal in  or  above  the  chink  except  hypenemia,  but  below  the  cords  he  could  see  what 
appeared  to  be  cedematous  folds  of  the  mucous  membrane  crowding  in  toward  the 
centre  and  more  marked  on  the  left  side. 

The  diagnosis  was  therefore  sub-glottic  oedema.  But  the  fact  that  she  was  also 
suffering  from  bronchitis  and  albuminuria  rendered  it  doubtful  as  to  whether  the  dysp- 
noea was  not,  in  part  at  least,  pulmonary.  On  listening  to  the  chest  no  air  could  be 
heard  entering  the  lower  posterior  portion  of  the  lungs,  and  a very  marked  up  and  down 
movement  of  the  larynx  could  be  detected  by  placing  the  fingers  over  it.  The  latter 
symptom  alone  was  sufficient  to  locate  tlie  obstruction  iu  the  glottis. 

I first  attempted  to  insert  a tube  two  and  a half  inches  long,  but  owing  to  the  short 
curve  on  the  introducer  it  was  necessary  to  detach  it  before  the  lower  end  of  the  tube 
had  passed  through  the  obstruction,  and  the  probe  point  being  thus  lost  the  tube 
caught  on  the  swollen  tissues  and  was  arrested.  A three  inch  tube  which  extended 
below  the  stricture  before  the  obturator  was  removed  passed  without  difficulty  and 
with  complete  relief  to  the  dyspnoea.  There  were  present  Dr.  J.  W.  Lyman,  H.  Gris- 
wold, G.  G.  Van  Schaick  and  Adolph  Rupp. 

On  inquiring  more  closely  into  the  history  of  this  patient  it  was  found  that  she  had 
contracted  syphilis  from  her  husband  some  years  before,  and  since  that  time  had  had 
several  miscarriages. 

After  the  tube  was  inserted,  she  refused  to  swallow  anything,  either  in  the  solid  or 
fluid  form,  and  was  fed,  at  first  by  the  rectum  and  later  by  the  stomach  tube. 

The  iodide  was  given  mixed  with  the  food  in  small  doses,  as  the  stomach  -would  not 
tolerate  large  ones,  and  mercury  was  administered  by  inunction. 


128 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  tube  was  removed  in  five  days  but  had  to  be  replaced  in  twenty  minutes,  owing 
to  the  rapid  return  of  the  dyspnoea.  It  was  again  removed  two  days  later  and  was  left 
out  for  half  an  hour,  while  Dr.  Geo.  M.  Lefferts,  who  was  called  in  consultation,  made 
a careful  laryngoscopic  examination.  Dr.  Lefferts’  diagnosis  was  sub-glottic  laryngitis. 
It  was  removed  for  the  third  time  January  24th,  ten  days  after  first  insertion.  This 
time  it  was  left  out  twenty-one  hours,  when  the  dyspnoea  became  so  urgent  that  I was 
obliged  to  replace  it,  and  Dr.  Griswold  removed  it  February  4th,  twenty-one  days  from 
first  insertion. 

It  produced  no  ulceration  nor  pain,  but  caused  excessive  coughing,  which  had  to  be 
moderated  at  night  by  opiates. 

A very  large  amount  of  tenacious  mucus  was  secreted,  which  required  considerable 
coughing  to  remove. 

March  14th,  or  about  six  weeks  after  the  tube  was  last  removed,  I was  hastily  sum- 
moned in  the  night  by  the  husband,  who  said  that  his  wife  would,  in  all  probability,  be 
dead  before  I reached  her.  I found  her  deeply  cyanosed  and  much  worse  than  at  any 
previous  time.  I was  obliged  to  make  three  attempts  before  I succeeded  in  placing  the 
tube  in  the  larynx,  and  they  had  to  be  made  very  rapidly,  as  cutting  off  the  small 
amount  of  air  that  was  entering  the  lungs  for  even  a short  time  would  have  produced 
asphyxia.  I was  without  assistance  on  this  occasion  and  had  heard  nothing  from  the 
case  for  some  time,  but  when  I met  Dr.  Lyman  the  next  day,  I learned  that  there  was 
a new  development.  The  left  arytenoid  was  very  much  swollen  and  anchylosed,  and 
on  its  anterior  surface  and  involving  a considerable  part  of  the  posterior  region  of  the 
larynx,  was  a growth  which  overlapped  the  chink  of  the  glottis.  This  explained  the 
difficulty  experienced  in  passing  the  tube  and  also,  in  part  at  least,  the  dyspnoea. 
Another  physician,  who  examined  this  patient’s  larynx  a short  time  previously, 
regarded  it  as  a perichondritis.  The  history  of  the  case,  the  appearance  and  location  of 
the  tumor,  and  the  absence  of  any  swelling  or  tenderness  on  the  outside  were,  I think, 
sufficient  to  exclude  this  and  to  leave  very  little  doubt  that  it  was  a gumma,  which 
had  developed  while  the  patient  was  said  to  be  taking  large  doses  of  the  iodide  and 
bichloride. 

The  tube  was  removed  in  a week  and  immediately  replaced  by  a larger  one  of  hard 
rubber,  which  was  prepared  in  the  following  manner:  Those  portions  of  it  which 
would  come  in  contact  with  the  diseased  surfaces  in  the  larynx  were  coated  with  gela- 
tine, liquefied  by  heating  and  dusted  over  while  still  moist  with  dry,  powdered  alum, 
and  as  one  layer  dried  another  was  applied  until  a sufficient  thickness  was  obtained. 
Gelatine  swells  considerably  as  it  absorbs  moisture,  and  the  dilating  power  of  the  tube 
thus  treated  can  be  temporarily  increased  to  any  extent,  with  or  without  the  astringent 
or  other  application.  This  can  he  prolonged  W covering  the  gelatine  with  a layer  of 
collodion,  which  prevents  the  too  rapid  absorption  of  moisture. 

This  tube  was  removed  for  the  last  time  March  28th,  having  been  in  the  larynx 
seven  days.  It  gave  rise  to  considerable  pain  and  irritation,  which  was  attributed 
principally  to  the  alum.  I have  not  seen  this  patient  since,  but  have  recently  been 
informed  that  there  is  still  some  dyspnoea  on  exertion  and  very  little  voice,  both  symp- 
toms being  probably  due  to  remaining  sub-glottic  thickening,  but  I have  no  knowledge 
of  the  recent  laryngoscopic  appearances. 

This  patient,  who  was  firmly  convinced  that  she  could  not  swallow  anything  during 
the  first  period  of  treatment,  subsequently  learned  how  to  swallow  a sufficient  quantity 
of  both  liquid  and  solid  nourishment  and  large  doses  of  the  iodide  without  much  diffi- 
culty. But  she  could  not  swallow  nearly  so  well  with  the  hard  rubber  as  with  the 
heavy  metal  tube,  for  the  latter,  as  she  expressed  it,  sank  lower  down  than  the  light 
tube.  She  could  not  distinguish  any  difl’erence  in  the  weight,  although  one  weighed 
one  ounce  and  three-quarters  and  the  other  only  one  hundred  grains.  There  was  no 


SECTION  XIII — LARYNGOLOGY. 


129 


j difference  apparently  in  the  ability  to  expectorate,  although  the  caliber  of  the  hard  rub- 
t ber  tube  was  almost  double  that  of  the  other.  It  will  be  remembered  that  the  first 
I patient  expressed  a decided  preference  for  the  light  tube,  which  was  the  same  oue  used 
in  both  cases,  aud  principally  because  she  expectorated  better  through  it. 

Although  my  experience  is  yet  very  limited  I have  some  reason  to  believe  that  while 
deglutition  will  be  more  difficult  with  the  hard  rubber  tube,  which  necessarily  stands 
, higher  in  the  larynx  on  account  of  its  lightness,  secretions  will  be  more  easily  expelled, 
as  they  do  not  appear  to  adhere  s > firmly  as  to  the  metallic  tube. 

CASE  IV. — This  patient  was  treated  by  Dr.  J.  J.  Reid,  iu  his  wards  at  Charity  Hos- 
pital, aud  briefly  reported  by  him  iu  the  Philadelphia  Medical  and  Surgical  Reporter  of 
i May  14th,  1887. 

J.  K.,  aged  twenty-two  years,  entered  hospital  May  1st,  1886.  He  stated  that  four 
i years  previously  he  had  contracted  a severe  cold,  accompanied  by  hoarseness,  which 
j had  continued  more  or  less  ever  since.  He  sought  relief  at  various  dispensaries  but, 
! steadily  growing  worse,  finally  entered  the  hospital. 

At  this  time  there  was  considerable  emaciation,  hoarseness,  cough  aud  dyspnoea  at 
night.  He  gave  no  direct  history  of  syphilis  but  there  was  necrosis  of  the  hyoid  bone, 
part  of  which  had  escaped  by  the  mouth,  leaving  a discharging  sinus  ou  the  inside. 
Ulceration  existed  around  the  base  of  the  epiglottis  and  involved  the  left  side  of  the 

■ larynx  to  the  arytenoids,  both  of  which  were  much  swollen  aud  partially  anchylosed, 
as  was  shown  by  the  fact  that  there  was  very  little  motion  of  the  vocal  cords.  Not- 
withstanding the  free  use  of  the  iodide  the  dyspnoea  increased,  especially  at  night, 
until  the  question  of  surgical  interference  had  to  be  considered.  I saw  the 
patient  with  Dr.  Reid  and  advised  against  intubation,  as  I believed  the  tube 
would  aggravate  the  existing  ulceration.  Dr.  Reid  thought  differently  and  inserted  a 
small  tube  on  Sept.  20th,  1886,  which  was  coughed  out  iu  twenty-one  hours.  Strange 
as  it  may  seem  it  did  not  give  rise  to  much  irritation,  or  at  least  the  patient  made 
no  complaint.  He  was  able  to  take  nourishment  well  and  slept  comfortably  without 
opiates,  except  a dose  immediately  after  the  insertion  of  the  tube.  The  same  day  a 
larger  tube  was  introduced  aud  expelled  in  twenty-four  hours.  A still  larger  one  was 
then  used,  and  retained  only  half  an  hour.  As  the  dyspnoea  was  now  much  relieved 
no  tube  was  used  for  a week,  when,  on  September  29th,  one  of  much  larger  size  was 
introduced  and  retained  for  eighteen  days  and  then  rejected,  while  the  patient  was 
sitting  up.  There  was  a slight  return  of  the  dyspnoea  on  Dec.  15th,  1886,  and  the  same 
tube  was  inserted,  for  only  24  hours.  He  left  the  hospital  soon  after,  to  resume  work  as 
a cigar  maker.  He  was  seen  the  following  June,  six  months  after  the  final  removal  of 
the  tube,  and  was  then  working  at  his  trade,  and  had  had  no  return  of  the  dyspnoea. 

Case  v. — This  case  was  operated  on  by  Dr.  Dillon  Browu,  assisted  by  Drs.  W.  H. 
Wilmer  and  Howard  Lilienthal.  There  were  also  present  Drs.  H.  E.  Sanderson,  H.  S. 
Stark,  G.  C.  Rich,  E.  F.  Walsh,  and  C.  E.Giddings. 

The  patient  was  a German,  aged  39  years,  who  for  some  time  had  been  subject  to 
severe  attacks  of  laryngitis,  accompanied  by  dyspnoea  ; on  laryngoscopic  examination 
a sub-glottic  neoplasm  was  discovered,  for  the  removal  of  which  a high  tracheotomy 
was  performed  on  December  24th,  1886.  The  growth  was  found  to  be  very  vascular, 
and  on  scraping  it  out  with  a curette,  a piece  of  a lucifer  match,  three-quarters  of  an 
inch  long,  was  discovered  imbedded  in  its  centre.  The  cannula  was  replaced  for  three 
days,  then  removed  and  the  wound  allowed  to  heal.  As  it  did  so  the  dyspnoea  increased, 
until,  on  January  18th,  1887,  while  the  patient  was  almost  asphyxiated  aud  pulseless, 
Dr.  A.  G.  Gerster  reopened  the  trachea  aud  inserted  the  cannula.  Niue  days  later,  when 
i the  patient  had  regained  sufficient  strength,  Dr.  Gerster  laid  open  the  thyroid  cartilage 

■ to  seek  and  remove,  if  possible,  the  cause  of  the  obstruction.  The  notes  furnished  me 
merely  state  that  the  cannula  was  re-inserted,  but  give  no  further  particulars  of  the 

Vol.  IV— 9 


130 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


operation.  He  continued  to  wear  the  cannula  until  March  25th,  1887,  when  Dr.  Brown 
inserted  a tube  iu  the  larynx,  the  patient  being  under  the  influence  of  ether.  Two 
previous  attempts  had  been  made  without  ether  and  failed,  owing  to  the  same  difficulty 
that  I experienced  in  my  second  case,  viz.,  the  lower  end  of  the  tube  engaging  iu  the 
external  opening.  He  was  of  a very  nervous,  irritable  temperament,  and  the  tube  gave 
rise  to  excessive  irritation,  which  called  for  the  frequent  use  of  opiates. 

Notwithstanding  the  fact  that  he  was  very  sensitive  iu  regard  to  his  personal  appear- 
ance, and  very  anxious  to  get  rid  of  the  tracheal  caunula,  he  frequently  begged  to  have 
the  tube  removed  from  the  larynx.  The  irritation  was  not  so  great  after  the  first  day 
or  two,  but  it  is  safe  to  say  that  toleration  was  never  established  in  this  case. 

The  tube  was  removed  in  a week  and  there  was  no  return  of  the  dyspnoea,  but  as 
the  one  used  was  very  small  it  was  considered  safer  to  produce  further  dilatation  by  a 
larger  tube.  This  was  introduced  April  20th,  but  immediately  rejected  and  no  further 
attempt  was  made  and  none  was  necessary.  The  patient  was  last  seen  Aug.  12th,  in 
good  health  and  free  from  dyspnoea,  and  had  a good  voice. 

He  wTore  the  tracheal  cannula  three  months,  and  was  cured  by  wearing  a tube  in  the 
larynx  one  week. 

As  yet  I am  unable  to  speak  from  my  own  experience  in  regard  to  the  prognosis  in 
chronic  stenosis  of  the  larynx.  Permanent  cures  have  been  reported,  particularly  by 
Schroetter,  of  Vienna,  but  I have  no  knowledge  as  to  the  length  of  time  that  elapsed 
after  final  treatment  before  such  cases  were  reported  as  permauently  cured,  and  this  is 
the  important  point.  I might  report  my  second  case  now,  more  than  four  months  after 
the  removal  of  the  tube,  as  cured,  but  I believe  it  would  be  premature  to  do  so  even  at 
the  end  of  a year. 

No  one  would  call  a stricture  of  the  urethra  that  required  ten  or  more  years  for  its 
development  as  permanently  cured  because  it  had  not  returned  in  one  year  after 
thorough  dilatation  or  cutting. 

The  contraction  of  cicatricial  tissue  may  be  very  slow,  and  as  it  requires  only  a small 
portion  of  the  normal  lumen  of  the  air  passages  for  free  respiration  a considerable  degree 
of  contraction  must  exist  before  manifesting  itself  in  the  form  of  dyspncea. 

Cicatricial  tissue  produced  by  the  healing  of  deep  tertiary  ulcers,  if  situated  in  the 
sub-glottic  division  of  the  larynx,  such  as  was  present  iu  my  first  case,  will,  in  all 
probability,  require  occasional  stretching  throughout  life.  If,  on  the  contrary,  it  is 
confined  to  the  chink  of  the  glottis  the  prognosis  will  be  better,  as  here  we  have  the 
inspiratory  abduction  of  the  vocal  cords  twenty  times  per  minute,  which  must  antago- 
nize to  some  extent  the  tendency  to  reconstruction. 

We  know  that  cicatricial  tissue  in  other  parts  of  the  body  finally  loses  the  power  to 
contract  by  persistent  and  long-continued  stretching,  and  if  the  first  case  reported  could 
have  tolerated  the  tube  continuously  for  several  months  instead  of  a week  the  outlook 
would  have  been  better. 

The  third  case  was  not,  properly  speaking,  one  of  chronic  stenosis,  but  a specific 
inflammatory  infiltration,  which  required  only  constitutional  treatment  for  its  cure, 
the  temporary  use  of  the  tube  being  necessary  to  tide  over  the  immediate  danger  of 
asphyxia,  although  it  no  doubt  also  hastened  absorption  by  its  pressure. 

If  constitutional  treatment  be  neglected  in  a case  of  this  kind  deep  ulceration  will 
follow,  and  the  development  of  cicatricial  stenosis  is  then  only  a question  of  time. 

Syphilitic  lesions  of  the  larynx,  in  my  experience,  do  not  yield  as  readily  to  specific 
treatment  as  the  manifestations  of  this  disease  in  other  parts,  and  therefore  more  per- 
severance is  necessary. 

Iu  Dr.  Reid’s  case,  although  of  long  stauding,  the  ulceration  was  apparently  con- 
fined to  the  sub-glottic  region  aud  not  very  deep.  The  occasional  use  of  mercury  aud 


SECTION  XIII — LARYNGOLOGY. 


131 


the  iodide,  extending  over  a long  period,  would  probably  in  this  case  insure  a permanent 
! cure  ; without  this  it  will  be  very  likely  to  recur. 

In  Dr.  Brown’s  case  there  was  no  cicatricial  tissue,  but  simply  inflammatory  thick- 
ening produced  by  the  presence  of  a foreign  body.  The  removal  of  this  still  left  more 
or  less  thickening,  and  what  was  probably  more  important,  partial  anchylosis  of  the 
arytenoids,  from  want  of  use.  All  that  is  necessary  to  effect  a cure  in  such  a case  is  to 
I produce  sufficient  dilatation  to  admit  air  through  the  larynx  and  thus  excite  contraction 
of  the  abductor  muscles  ; or,  in  other  words,  to  set  the  machinery  in  motion. 

Thus  far  I have  dealt  almost  exclusively  with  facts.  In  the  concluding  part  of  my 
paper,  which  treats  of  stricture  of  the  trachea,  I find  it  necessary  to  fall  back  on  theories, 
as  I have  not  yet  treated  a case  of  this  kind.  These  theories  are  not  visionary,  but,  on 
the  contrary,  are  strongly  supported,  if  not  demonstrated,  by  the  foregoing  facts. 

The  oval  laryngeal  tubes  are  not  suitable  for  stricture  of  the  trachea,  which  retains 
the  cylindrical  form  and  requires  tubes  to  correspond.  I had  one  of  this  kind  made  for 
an  old  lady,  aged  sixty-eight  years,  who  was  suffering  from  stricture  of  the  trachea 
caused  hy  a process  from  a large  bronchocele  surrounding  it.  I saw  this  patient  with 
Dr.  Edmund  J.  Palmer,  at  the  suggestion  of  Dr.  Henry  B.  Sands,  with  a view  to  prac- 
ticing intubation.  The  tumor  was  very  large,  especially  in  front,  covering  the  whole 
of  the  trachea  and  the  greater  part  of  the  larynx.  Tracheotomy  did  not  offer  much 
hope,  as,  in  order  to  get  into  the  trachea  below  the  obstruction,  a large  mass  of  vascular 
tissue  would  have  to  be  cut  through,  and  none  of  the  ordinary  tracheal  cannulas  would 
be  long  enough  to  reach  it.  To  open  into  the  larynx  above,  where  there  was  less  of  the 
growth,  would  still  leave  the  stricture  below.  Dr.  Sands,  who  was  first  called  to  con- 
sider the  advisability  of  opening  the  trachea,  did  not  give  much  encouragement,  and 
would  operate  only  in  case  of  impending  asphyxia. 

Before  I could  procure  the  tube  which  I intended  to  use,  the  patient  insisted  on 
returning  to  her  old  home  in  the  western  part  of  the  State,  where  she  subsequently  died. 

That  portion  of  the  tumor  which  surrounded  the  trachea,  by  also  pressing  on  the 
•oesophagus  interfered  very  much  with  deglutition.  Solids  could  scarcely  be  swallowed 
at  all,  and  even  had  we  succeeded  in  relieving  the  dyspnoea,  death  from  inanition  was 
only  a question  of  time,  as  it  would  have  been  impossible  to  pass  a stomach  tube. 

The  difficulty  of  intubating  such  a case  would  result  from  the  small  size  of  the 
stricture.  I am  as  fully  convinced  as  if  I had  tried  it,  that  it  would  have  been  impos- 
sible to  pass  a tube  as  large  as  the  one  I have  shown  without  previous  divulsion  under 
ether.  This  I intended  doing  with  the  smallest  of  Schroetter’s  long  vulcanite  tubes. 

Many  years  ago  I heard  the  late  Prof.  F.  H.  Hamilton  relate  his  experience  with  an 
almost  identical  case.  His  patient  was  a clergyman  far  advanced  in  years,  who,  for  the 
greater  part  of  his  life,  had  suffered  from  a large  goitre.  When  death  by  strangulation 
was  only  a question  of  a little  time,  Dr.  Hamilton  performed  tracheotomy,  but  the 
insertion  of  the  cannula  gave  no  relief  and  the  patient  died  soon  afterward.  The 
autopsy  showed  that  the  trachea  at  the  seat  of  the  stricture  was  reduced  to  the  size  of 
a crow-quill.  I have  no  recollection  of  further  particulars,  but  the  tube  must  have 
heen  inserted  above  the  obstruction,  and  was,  of  course,  many  times  too  large  to  pass 
through,  even  if  it  had  been  long  enough. 

There  is  scarcely  any  doubt  that,  of  all  strictures,  that  of  the  trachea  is  the  most 
unfavorable  as  regards  permanent  cure. 

It  can  unquestionably  be  dilated  if  not  situated  too  near  the  bifurcation,  but  the 
power  of  the  contracting  tissue,  whether  on  the  inside  or  outside,  which  is  sufficient  to 
overcome  the  resistance  offered  by  the  almost  bony  rings  of  the  adult  trachea,  will  not 
be  destroyed  by  temporary  dilatation. 

My  second  case  of  chronic  stenosis  of  the  larynx,  who  retained  a tube  in  the  larynx 


132 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


continuously  for  over  ten  months  without  its  becoming  obstructed,  suggested  another 
plan  of  treating  stricture  of  the  trachea. 

It  consists  of  first  accomplishing  sufficient  dilatation  with  tubes,  such  as  I have 
already  shown,  of  different  sizes,  and  then  passing  a tube  of  proper  length  and  having 
a shoulder  just  large  enough  or  small  enough  to  pass  completely  through  the  larynx  and 
rest  on  the  upper  surface  of  the  stricture.  It  would  also  have  a retaining  swell  near 
the  lower  extremity,  to  prevent  it  from  being  driven  upward  by  coughing. 

If  the  stricture  be  situated  too  low  down  to  be  reached  through  the  larynx,  it  would 
be  necessary  to  lay  open  the  trachea  at  the  seat  of  obstruction  and  insert  a tube  of  hour- 
glass shape,  such  as  I have  here,  and  close  the  wound  over  it. 

I do  not  entertain  the  slightest  doubt  that  such  a tube  can  be  worn  for  a lifetime 
without  danger  of  obstruction  from  secretions,  because  the  expulsive  power  of  the 
cough  would  not  be  impaired,  as  it  necessarily  is  when  the  tube  occupies  the  larynx 
and  prevents  approximation  of  the  vocal  cords.  Neither  would  there  be  anything  to 
fear  from  excessive  irritation,  as  the  trachea  is  infinitely  less  sensitive  than  the  larynx. 

As  it  stands  at  present,  without  actual  demonstration,  I know  of  no  impediment  to 
the  permanent  wearing  of  a tube  in  the  trachea,  save  the  deposit  of  calcareous  matter, 
to  which  I have  already  alluded,  and  this  was  probably  caused  by  electrical  currents 
excited  by  the  copper  and  zinc  alloy  of  which  the  tube  was  composed.  I have  noticed 
a slight  amount  of  this  deposit  on  the  gold-plated  brass  tubes  when  retained  for  only 
one  week,  but  not  the  least  trace  of  it  on  the  vulcanite  tube  when  worn  for  the  same 
time. 

To  avoid  this  objectionable  feature,  therefore,  and  at  the  same  time  insure  dura- 
bility, it  will  be  necessary  to  have  such  tubes  constructed  of  hard  rubber  burned  on  a 
framework  of  metal,  or  cast  in  pure  gold. 

A tube  passed  into  a stricture  in  the  trachea  through  the  larynx  can  also  be  removed 
through  the  same  channel  by  making  the  curved  part  of  the  extractor  long  enough. 

I am  not  aware  that  any  attempt  has  ever  been  made  to  exsect  the  strictured  por-  . 
tion  of  the  trachea,  but  it  is  quite  probable  that  the  great  elasticity  of  this  tube,  which 
is  necessary  to  permit  of  that  elongation  which  takes  place  during  the  act  of  swallow-  j 
ing,  would  admit  of  the  removal  of  at  least  half  an  inch  without  anything  more  than 
temporary  interference  with  deglutition. 

A child’s  trachea  suspended  with  a slight  weight  attached  increases  three-quarters 
of  an  inch  in  length,  and  the  adult  trachea,  being  much  longer,  will  gain  in  propor-  ; 
tion. 

I have  also  devised  but  not  yet  perfected  a laryngeal  speculum,  which  has  never  been 
used  except  on  the  cadaver.  It  is  intended  to  facilitate  the  removal  of  sub-glottic  | 
growths  by  holding  the  glottis  open  and  the  epiglottis  erect.  It  may  be  so  constructed 
that  it  will  also  act  as  a snare  for  pedunculated  tumors  situated  on  the  lateral  aspects  , 
of  the  larynx  below  the  cords,  and  should  be  particularly  useful  in  young  children 
where  it  is  difficult  or  impossible  to  use  the  mirror.  There  is  very  little  doubt  that  it 
will  be  more  effectual  than  the  dry  sponge  used  by  Yoltolini  for  this  purpose. 


DISCUSSION. 

Mr.  Lennox  Browne,  of  London,  spoke  in  the  highest  terms  of  the  grand  suc- 
cess that  had  attended  the  years  of  study  and  patient  work  of  Dr.  O’ Dwyer,  and 
said  that  he  was  commissioned  to  purchase  a complete  outfit  for  his  hospital.  He 
was  surprised  that  tubes  could  be  retained  in  so  sensitive  an  organ. 

Dr.  O’Dwver  closed  the  discussion,  and  exhibited  a laryngeal  speculum  and  a 
snare  for  removal  of  membrane  and  small  papillomata  from  below  the  vocal  cords. 


SECTION  XIII — LARYNGOLOGY.  133 

A NEW  SNARE  AND  ECRASEUR. 

UN  SERRE  NCEUD  NOUVEAU  ET  UN  ECRASEUR. 

EIN  NEUER  SCHLINGENSCHNURER  UND  ECRASEUR. 

BY  CHARLES  SLOVER  ALLEN,  M.D., 

Of  New  York. 

Dr.  C.  Sloyer  Allen,  of  New  York,  presented  to  the  Section  a new  snare  and  ecra- 
seur.  The  advantages  of  the  snare  are:  that  it  can  be  used  with  one  hand  entirely, 
while  the  other  is  left  free  to  hold  a speculum  or  other  instrument;  far  greater  power  can 
be  obtained  than  where  the  screw  is  used,  and  it  can  be  applied  quicker.  It  is  made  of 
steel  throughout,  and  will  stand  the  heaviest  work. 

The  ends  of  the  wire  are  fastened  by  means  of  an  eccentric  moved  by  a small  lever. 

The  power  is  applied  through  the  action  of  a (Rouble  lever,  instead  of  a screw. 

The  wire  loop  can  be  instantly  contracted  around  the  tissue  to  be  removed  with 
the  force  of  the  fingers  pulling  down  the  slide.  It  is  held  there  automatically  and  pre- 
vented from  slipping  back.  Alternating  pressure,  with  index  and  middle  fingers  in  the 
rings,  brings  it  down  with  enormous  power,  through  the  action  of  a transverse  lever, 
which  carries  dogs  or  catches  past  ratchet  teeth  placed  on  both  sides  of  the  shaft. 


A,  A,  rings  for  middle  and  fore  finger,  united  by  a lever,  which  is  pivoted  above  and  below  to  the  sliding 
body.  The  ratchet  catches,  G,  G,  are  pivoted  to  this  lever  on  either  side  and  fit  into  the  ratchet  teeth 
on  the  sides  of  the  square  frame,  0.  D is  the  thumb  ring,  fastened  by  a swivel.  The  lever,  B,  fastens 
the  wire  ends,  H.  H,  by  means  of  an  eccentric,  beneath  which  they  pass.  The  flattened  end  of  the 
tube  prevents  rotation  of  the  wire  loop,  F.  Simultaneous  pressure  on  rings,  A,  A,  contracts  loop 
quickly  with  only  full  power  of  the  fingers.  If  they  are  pressed  upon  alternately,  then  one  ratchet 
catch  at  a time  is  drawn  down  over  the  teeth,  while  the  other  holds  fast.  The  loop  is  then  contracted 
more  slowly,  with  great  leverage  power. 


The  authors  of  the  following  two  papers  not  being  present,  they  were  read  by 
title  only : — 

UBER  NERVOSEN  HUSTEN  UND  SEINE  BEHANDLUNG. 

ON  NERVOUS  COUGH  AND  ITS  TREATMENT. 

SUR  LA  TOUX  NERVEUSE  ET  SON  TRAITEMENT. 

VON  DR.  OTTOMAR  ROSENBACH, 

Breslau,  Deutschland. 

Wir  rechnen  zur  Categorie  des  nervosen  Hustens  diejenigen  Fa  lie,  bei  welchen  die 
genaueste  Localuntersuchung  der  Nase,  des  Larynx,  des  Pharynx  und  der  Lungen 
weder  eine  der  sonstals  ursachliches  Moment  andauernder  Hustenparoxysmen  geltenden 
Gewebsstijrungen,  noch  jene  Form  abnormer  Schleimsecretion,  welche  bisweilen  ohue 
sichtbare  Texturerkrankung  der  Schleimhaut  die  Quelle  eines  Husten  ausldsenden 


134 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Reizes  ist,  nachzuweisen  verraag, — Fiille  also,  bei  denen  iu  Ermangelung  jeder  palpablen 
Schleirahautveranderung  eine  rein  nervose  Storung,  eine  Leitungshyperiisthesie  in  den 
den  Hustenreflex  vermittelnden  Bahnen,  als  Ursache  der  Erscheinungen  angesehen 
werden  muss.  Da  dieser  Krankheitsgruppe  ausser  dem  eben  erwiihnten  eigenthiini- 
lic.hen  Entstehungsmecbanismus  gewisse  besondere  Characteristica  beziiglich  der 
Aetiologie,  des  Yerlaufes  der  ausseren  Erscbeinung  und  vor  Allem  der  Therapie 
zukommen,  so  glauben  wir  ibr  auf  Grund  eines  ziemlich  umfangreicben  Materials  eine 
Sonderstelluug  gegen'uber  den  anderen  Formen  des  Hustens  einraumen  zu  diirfen, 
indem  wir  zugleich  hervorheben,  dass  die  einzelnen  Fiille,  aus  denen  wir  unsere 
Erfabrungeu  abstrahirt  haben,  einer  sorgf'altigen  Kritik  und  Sichtung  unterworfen 
werden  mussteu.  Es  ist  in  der  That  leicht  ersichtlicli,  dass  der  blosse  negative  Local- 
befund  nicbt  allein  geniigt,  einem  Falle  den  Stempel  der  functionellen  nervdsen  Geuese 
aufzudr'iicken,  weil  ja  auck  schwere  orgauische  Lasionen  des  Centralnervensystems 
selbst,  oder  der  Nachbarschaft  der  den  Husten  vermittelnden  Bahnen  lange  Zeit  ohne 
audere  Symptome  als  die  einer  erhohten  Hustenthiitigkeit  verlaufen  konnen  (Aneurys- 
men  der  Aorta,  die  auf  den  Vagus  und  Recurrens  dr'ucken,  Tabes  etc.).  Es  muss  dem- 
nach  in  jedem  einzelnen  Falle  nicht  nur  eine  genaue  Allgemeinuntersuchung  vor- 
genommen  werden,  sondern  es  diirfen  auch  nur  diejenigen  Kranken  zu  unserer  Gruppe 
geziihlt  werden,  bei  denen  wiihrend  einer  l'angeren  Beobachtungsdauer  vor  oder  nach 
der  Heilung  keinerlei  auf  orgauische  Lasionen  hinweisende  Symptome  zum  Vorschein 
gekommen  sind,  und  wir  konnen  deshalb  die  hier  beschriebene  Form  des  Hustens  als 
die  des  benignen  nervosen  Hustens  bezeichnen,  eine  Terminologie,  die  in  bezeichnender 
Weise  die  Hauptckaracteristica  des  Zustandes,  das  blosse  Symptom  des  Hustens  und 
die  nervose  Genese  desselben  ebenso  in  den  Vordergrund  stellt,  wie  sie  die  Abwesenkeit 
jeder  Gewebsstorung  postulirt. 

Wir  haben  zwei,  schon  der  ausseren  Ersckeinungsweise  nach  klinisch  leicht  zu 
differenzirende  Categorien  des  nervdsen  Hustens  — die  im  Wesentlichen  von  den  Alters- 
verrchiedenheiten  der  befallenen  Individuen  beeinflusst  zu  sein  scheinen — zu  unter- 
scheiden,  niimlich  erstens  eine  paroxysmale  Form,  die  des  krampfhaften,  rauheu, 
bellenden,  stark  explosiven  Hustens,  bei  der  entweder  zwischen  jedem  einzelnen  der 
verhaltnissmassig  lange  anhaltenden  Hustenstdsse  eine  sehr  kurze  Inspiration  ein- 
geschaltet  ist,  oder  bei  der  mekrere  sehr  heftige,  aber  kiirzere  exspiratorische  Explo- 
sionen  dicht  auf  einander  folgen,  bevor  eine  sehr  tiefe,  bisweilen  tdnende  Inspiration 
einsetzt,  die  luiufig  den  Anfall  beschliesst,  hauiig  aber  auch  einen  neuen  einleitet,  und 
zweitens  das  kurze,  trockene,  aus  drei  bis  vier  ganz  gleichen,  durch  keine  inspiratorische 
Pause  getrennten,  riiuspernden  Bewegungen  zusammengesetzte  Husteln.  Das  weseut- 
liche  Kennzeichen  der  ersten  Categorie  ist  also  das  forcirte,  stossweise,  ungleichmassige 
Auftreten  des  Hustens,  das  der  zweiten  das  gleichf  drmige,  monotone,  ohne  Anstrengung 
erfolgende  Riiuspern  ; die  Anfalle  der  ersten  Gruppe  pflegen,  nachdem  eine  grdssere 
Anzahl  vou  Hustenstdssen  in  der  oben  geschilderten  Gruppenform  erfolgt  ist,  fur 
liingere  Zeit  aufzuhiiren  (Pausen  vou  mehrstiindiger  Dauer  sind  nicht  selten),  wiihrend 
das  Husteln  bei  der  zweiten  Gruppe  ein  continuirliches  Pkanomen  ist,  welches  oft 
kaum  minutenlange  Intervalle  aufweist.  Uebergiinge  zwisclieu  beiden  Formen  kommen 
nicht  so  selten  vor,  seltener  Mischformen  ; es  geht  dann,  wie  wir  beobachtet  haben,  die 
erste  in  die  zweite  Form  liber,  wiihrend  der  umgekehrte  Vorgaug  unseres  Wisseus 
nicht  Platz  greift. 

Was  das  Vorkommen  des  nervosen  Hustens  bei  deu  verschiedeuen  Altersklassen 
und  Gescblechtern  anbetrifft,  so  ist  hervorzuheben,  dass  die  Anfalle  der  ersten  Categorie 
fast  ausnalunslos  bei  jiingeren  Personeu  iu  der  ersten  Lebenshiilfte  zur  Beobacktung 
kommen,  dass  sie  in  ausgepriigter  Form  nur  die  zwei  ersten  Lebensdeceunien,  nament- 
lich  die  Zeit  bis  zur  Pubertiit,  zum  Schauplatz  haben,  dass  jenseits  der  zwauziger  Jahre 
die  Zahl  der  Erkrankten,  sowie  die  Intensitiit  und  Extensitiit  der  Anfalle  eine  aufFallend 


SECTION  XIII — LARYNGOLOGY. 


135 


geringere  wird.  Beide  Geschlecliter  werden  Lis  zur  Pubertat  gauz  gleichmassig 
: befallen  ; doch  scbeint  von  da  ab  das  weibliche  Gesclilecht  mehr  zu  der  gesebilderteu 
Form  des  nervosen  Husteus  disponirt  zu  sein. 

Die  Anfalle  der  zweitcu  Categorie  finden  sich  in  reiner  Form  nur  bei  Erwachsenen, 
und  zwar  vorzugsweise  bei  Frauen  ; sie  kommen  bei  MUnnern  auch  vor,  aber,  wie 
gesagt,  doeb  nur  in  einer  verschwindenden  Anzahl  von  Fallen.  Hier  zeigt  sicli  dann 
auch  die  oben  erw'ahute  Mischform  des  Hustens  am  haufigsten.  Bei  jiingeren  Leuten 
findet  sich  das  Hiisteln  nur,  wenn  bereits  liingere  Zeit  vorher  der  explosive  Husten 
voransgegangen  ist ; das  Hiisteln  ist  hier  gewissermaassen  das  zweite,  mehr  chronische 
Stadium  des  Leidens,  wahrend  es  bei  Erwachsenen  oft  auch  die  primare  Affection 
repraseutiren  kann. 

Beziiglich  des  Yerlaufs  und  der  Beschaffenheit  der  einzelnen  Anfalle  mag  besonders 
i bemerkt  werden,  dass  in  beiden  Gruppen  in  der  Regel  kein  Schleim  expectorirt  wird, 
und  dass  nur  bei  schweren  und  langdauernclen  Fallen  der  ersten  Gruppe  am  Ende  des 
Anfalles  etwas  Speichel,  der  wahrend  der  heftigen  Exspirationsstosse  nicht  verschluckt 
werden  kann,  oder  etwas  zalier  Rachenschleim,  wie  er  in  diinner  Schicht  ja  stets  die 
l Rachenschleimhaut  zu  uberziehen  pflegt,  herausbefbrdert  wird.  Hier  mag  iudessen 
gleich  erwahnt  werden,  dass  in  einer  kleinen  Anzahl  von  Fallen,  die  zur  Categorie  des 
nervosen  Hustens  gehiiren,  doch  auch  eine  betrachtlichere  Schleimabsonderung  vor- 
handen  sein  kann,  die  aber  nicht  Zeichen  einer  primaren  Texturerkrankung  der 
i Schleimliaut,  sondern  nur  eine  mechanische  Folge  der  der  Schleimhaut  durch  die 
audauernden,  wiederholten,  heftigen  Hustenstosse  zugef  ugten  Insulte,  also  ein  secun- 
d'ares  Symptom,  sind.  Wir  werden  weiter  uuten  diese  scheinbare  Ausnahme,  die  aus 
dem  Rahmen  unserer  oben  gegebenen  Definition  heraustritt,  naher  zu  erbrtern  haben. 

Die  einzelnen  Anfalle  kbnnen  in  sehr  verschiedener  Haufigkeit  und  Heftigkeit 
einander  folgen,  und  wir  haben  bereits  darauf  hingewiesen,  dass  bei  der  ersten  Form 
des  Hustens  oft  mehrstundige  Pausen  zwischen  den  einzelnen,  in  besondere  Gruppen 
von  Husteustbssen  zerfallenden  Paroxysmen  bestehen,  wahrend  bei  der  zweiten  Form 
derselben  das  Hiisteln  sich  mit  unveranderter  Gleichmassigkeit  ohne  liinger  dauernde 
Iutervalle  wiederholt. 

Die  Anfalle  fehlen  stets  im  Schlafe  und  wenn  die  Aufmerksamkeit  des  Patienten 
auf  irgend  eine  Weise  abgelenkt  wird  ; siehiiufen  sich  und  nehmen  auch  an  Intensitat 
zu,  wenn  die  Kranken  beobachtet  oder  arztlich  untersucht  werden,  wenn  sie  psychisch 
erregt  sind,  wenn  sie  aus  dem  Freien,  wo  die  Anfalle  oft  ganz  cessiren,  in’s  Zimmer 
treten  ; sie  treten  nicht  auf,  wenn  die  Patienten  in  anregender  Unterhaltung  lebhaft 
sprechen,  oder  wenn  sie  essen.  Aber  selbst  in  diesen  Fallen  kann  man  den  Husten 
heryorrufen,  wenn  man  die  Gedanken  des  Patienten  auf  sein  Leiden  hinfiihrt,  oder 
wenn  man  ihn  auffordert,  zu  husten.  Auffallend  ist  es,  dass  grosser©  Kinder  und 
Erwachsene  nach  einer  gewissen  Dauer  des  Leidens  auch  bei  schwereren  Anf alien 
weder  cyanotisch  werden,  noch  besondere  Zeichen  von  Dyspnoe  zeigen,  so  dass  sie  nach 
dem  Aufhijren  der  scheinbar  so  sehr  qualenden  Hustenstosse — im  Gegensatz  zu  anderen 
Formen  des  Hustens — sofort  ohne  jede  Austreuguug  im  Gesprach  fortfaliren  kiinnen; 
auflfallend  ist  auch  in  diesen  Fallen  und  denen  der  zweiten  Categorie,  bei  denen  ja 
wegen  der  Kiirze  und  geringeu  Intensitat  der  Anfalle  Zeichen  von  Dyspnoe  iiberhaupt 
nicht  zu  erwarten  sind,  der  geringe  Einfluss  des  Hustens  auf  den  Puls,  der  oft  weder 
Frequenz  noch  Character  merklich  iindert.  Es  wird  dieses  auf  den  ersten  Blick 
befremdende  Verhalten  dann  erklurlich,  wenn  man  die  Patienten  wahrend  der  Husten- 
paroxysmen  genau  beobachtet;  der  ganze  Act  des  Hustens  geht  in  diesen  Fallen  ebeu 
unter  ganz  eigenthiimlich  veranderten  ausseren  Bedinguugen  in  Scene.  Die  Patienten 
sind  niimlich  im  Stande,  bei  einer  ganz  speciellen,  nicht  lcicht  nachzuahmenden  Fixation 
des  Thorax  (in  Inspirationsstellung  oder  einer  dieser  ahnlichen  Position)  durch  ganz 
kurze  Stbsse  mit  dem  oberen  Theil  der  Bauchmuskeln  einen  lauten,  bellenden  Husten 


136 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


zu  erzeugen,  ohne  die  Glottis  vollig  zu  schliessen.  Dieses  Yerhalten,  d.  h.  die  Anwen- 
dung  eines  ganz  besonderen,  vou  dem  Patienteu  willkurlich  oder  unwillkurlich  ein- 
ge’ubten  Mechauismus,  liefert  den  Schliissel  fur  die  eigenthumlicbe  Erscheinung,  dass 
die  sonst  mit  eiuer  starkeu,  plbtzlichen  Compression  des  Brustinhaltes  bei  Fixirung  des 
Zwerelifelles  vergesellschafbete  maximale  Druckerhdhung  und  der  daraus  resultirende 
sch'adliche  Effect  fur  die  Circulation  fast  vollst'andig  in  Wegfall  kommt.  Da  feruer 
bier  auch  der  durcb  die  entzundlichen  Veriinder  ungen  im  Inneren  des  Larynx  sonst 
bewirkte  Glottiskrampf,  welcher  die  Anf'alle  des  Keuchhustens  sonst  so  sehr  quiilend 
macht,  fehlt,  so  ist  es  erklarlich,  dass  die  Wirkung  selbst  anscheiuend  schwerer  Anf'alle 
eine  so  geringe  ist,  dass  nach  Beendigung  des  Anfalles  keine  merkliche  Erscblaffung 
des  Organismus  oder  eine  wesentliche  Alteration  der  kdrperlichen  Functionen  vor- 
handen  ist,  und  dass  sch'adliche  Folgeu  bei  dem  nervdseu  Husten  lange  ausbleiben 
kbnneu.  Hier  bleibt  noch  zu  erw'ahnen,  dass  die  oben  erwahute  pfeifende  oder  besser 
tbnende  Inspiration,  die  sich  zwischen  die  Anf'alle  einschiebt,  durchaus  nicht  durcb 
einen  Glottiskrampf  bedingt  ist,  deun  es  liisst  sich  laryngoscopisch  feststellen,  dass  sie 
bei  relativ  weiter  Glottis  entsteht,  dass  sie  also  nur  durch  die  Reibimg  des  willkurlich 
betr'achtlieh  verstarkten  inspiratorischen  Luftstromes  (an  den  sich  nur  wenig  nahemden, 
sich  sogar  bisweilen  in  normaler  Weise  von  einander  entfernenden  Stimmbandern) 
hervorgerufen  wird.  Wenn  die  Intensit'at  der  Anf'alle  eine  sehr  betr'achtliche  wird,  so 
kann  es  im  ersten  Stadium  der  Erkrankung  bei  Kindern  und  Frauen  am  Eude  der 
Attaque  zu  Wiirgen  oder  Erbrechen  kommen,  ein  Yorgang,  der  — im  Gegensatze  zuden 
Paroxysmen  des  Keuchhustens  — im  Anschlusse  an  die  Mahlzeit  durchaus  nicht  haufiger 
stattfindet,  als  bei  leerem  Magen.  Gewbhnlich  wird  auch,  selbst  bei  gef  iilltem  Magen, 
nur  ein  geringer  Bruchtheil  des  Inhaltes  ausgeworfen.  Nach  sehr  hefbigen  Anfallen 
ergiebt  die  laryngoscopische  Untersuchung: — bei  anamischen  Individuen — bisweilen  eiue 
leichte,  schnell  verschwindende  Rbthung  der  Trachealschleimhaut  oder  der  Plica  inter- 
arytaenoidea  ; Blutungen  scheinen  selbst  bei  sehr  starken  Anfallen  sehr  selten  zu  seiu; 
in  zwei  Fallen  fanden  sich  in  dem  expectorirten  diinnen,  nur  aus  Speiehel  bestehenden 
Expectorate  kleine  Blutpunkte,  fur  deren  Urspruug  die  laryngoscopische  Untersuchung 
keinen  Anhaltspunkt  ergab. 

Unter  den  Folgezust'anden  des  nervdsen  Hustens  sind,  abgeselien  von  einer  Reihe 
anderer  nervdser  Symptome,  Reizbarkeit,  Launenhaftigkeit,  theilweise  deprimirter 
Gemuthsstimmung,  Verdauungsstorungen,  vor  Allem  zwei  zu  erw'ahnen,  niimlich  die 
secundare,  schou  oben  beruhrte  Schleimhautaffection  des  Larynx  und  die  Atelectase 
gewisser  Lungenpartieen.  Was  die  erstere  betrifft,  so  ist  dariiber  Folgendes  zu  sagen. 
Bei  vielwbchentlichem  Bestelien  sehr  schwerer  Attaquen  tritt  in  den  Fallen,  in  denen 
der  oben  geschilderte  eigenthumlicbe  Mechanismus  des  Hustens,  durch  den  die  Span- 
nung  und  Reizung  der  Stimmbander  vermindert  wird,  nicht  in  Anwendung  kommt, 
eine  leichte  catarrhalische  Schwellung  der  Larynxschleimhaut,  namentlich  an  der 
Plica  interarytaenoidea,  anf,  welche  letztere  dann  ebenso  wie  die  aryepiglottischeu 
Falten  einen  geringen  Schleimbelag  aufweist.  Wahrend  der  Hustenanfalle,  die  oft 
durch  ein  qualendes  Wiirgen  eingeleitet  werden,  wird  dann  eine  geringe  Quantitat 
zahen,  fadenzieheuden  Schleims,  der  in  manchen  Fallen  mit  Eiterflocken  uutermischt 
ist,  ausgeworfen,  und  dieser  Auswurf  kann  in  Verbindung  mit  der  bestehenden  Textur- 
veranderung  der  Schleimliaut  der  Diagnose  grosse  Schwierigkeit  bereiten,  da  die  Ent- 
scheidung,  ob  der  Husten  die  Folge  eines  Larynxcatarrhs  oder  dieser  die  Folge  des 
Hustens  ist,  iu  den  ersten  Tageu  der  Beobachtuug  und  oft  auch  nach  Lingerer  Zeit 
unmoglich  ist.  Eine  bestimmte  Diagnose  ist  nm  so  schwerer  zu  stellen,  als  man  ja  im 
Allgemeiueu  dem  Umstaiule,  dass  auch,  abweichend  von  dem  sonstigeu  Causal- 
zusammenhange,  der  Husten  als  soldier,  d.  li.  der  mechanische  Akt  des  Hustens,  eine 
wesentliche  Schleimhautaffection  zur  Folge  haben  kbnne,  sehr  wenig  Reclmung  tragt, 
obwohl  es  ja  auf  der  Hand  liegt,  dass  die  starke,  mit  den  Hustenstdssen  verbundene 


SECTION  XIII — LARYNGOLOGY.  137 

Zerrung  und  Quetschung  des  Gewebes  eine  Quelle  bestlindigen  Reizes  fiir  die  zarte 
Schleimhaut  abgeben,  uud  ebenso  einen  entziindlichen  Zustaud  in  ilir  hervorrul'en  und 
uuterlialten  kann,  wie  jede  andere  Schlidlichkeit.  Wir  kommen  bei  Eriirterong  der 
Diaguose  und  namentlick  der  Therapie  des  Leidens,  die  die  Bedeut.ung  des  alteu 
diagnostischen  Satzes  “noscere  ex  juvantibus”  klar  illustrirt,  auf  einige  in  dieser 
Beziekuug  wichtige  Fuukte  nocb  zuriick. 

Die  zweite  wichtige  Folgeerscheinung  Linger  daueruden  nerviisen  Hustens  besteht 
in  einer  eigentliiimlichen  Verlinderung  des  Athemgeriiusches  liber  der  hinteren  Partie 
der  Lungenspitzen.  Man  fiudet  daun  bei  der  Untersuchung  der  Fossa  supraspinata  das 
iuspiratorische  Athmen  betrlichtlich  abgeschwiicht ; bisweilen  hat  es  den  vesicuhiren 
Character  ganz  verloren  und  erscheint  unbestimmt  oder  hauchend  ; oft  vernimmt  man 
statt  des  Athemgeriiusches  nur  reichliches,  klangloses,  kleinblasiges,  oft  knisterndes 
Rasseln.  Dieses  Rasseln  ist  namentlicli  auf  der  Hbhe  der  Inspiration  oder  nach  starken 
Hustens  tossen  recht  deutlich  ; dagegen  kann  es  nach  einer  Reihe  tiefer  Athemziige 
; vbllig  verschwinden,  um  einem  ganz  normalen  Befunde  Platz  zu  machen.  Wenn  hin- 
gegen  der  Patient  fortfiihrt,  in  wenig  ergiebiger  Weise  zu  athmen  und  seine  Husten- 
anflille  in  gewohnter  Weise  zu  produciren,  so  kann  man  nach  kurzer  Zeit  wieder  das 
. ausgesprochenste  Rasseln  und  das  Verschwinden  des  normalen  Athemgeriiusches  con- 
statiren,  und  man  ist  im  Stande,  den  Wechsel  der  beschriebenen  Erscheinungen 
beliebig  oft  zur  Beobachtung  zu  bringen.  Mit  der  Abnahme  der  Haufigkeit  und 
Intensitat  der  Anfiille  nlihert  sich  der  Lungenbefund  immer  mehr  dem  Normalen,  und 
wenn  die  Anfiille  erst  einige  Zeit  vbllig  ausgesetzt  haben,  so  kann  selbst  in  schweren 
Fiillen  die  genaueste  Untersuchung  keinen  pathologischen  Befund  mehr  constatiren  : 
liber  beiden  Lungenspitzen  vernimmt  man  mehr  oder  weniger  lautes,  aber  deutliches, 
l vesiculiires  Athmen  ohne  jedes  Nebengerliusch.  Aufifallend  und  daher  der  Erwiihnung 
werth  scheint  uns  die  Thatsache,  dass  sich  in  unseren  Fiillen  die  eigenthiimliche  Ver- 
iinderung  des  Athemgeriiusches  nur  auf  die  rechte  Fossa  supraspinata  beschrankt  zeigte; 

» doch  glauben  wir,  dass  es  sich  hier  nur  um  ein  zufiilliges  Zusammentreffen  handelt, 
da  kein  zwingender  Grand  dafiir  vorliegt,  dass  gerade  die  rechte  Lungenspitze  durch 
so  starke  Hustenparoxysmen  mehr  beeintriichtigt  werde,  als  die  der  anderen  Seite. 
Endlich  ist  noch  hervorzuheben,  dass  — und  es  ist  dies  in  differentiell-diagnostischer 
Beziehung  von  grosser  Wichtigkeit  — der  abnorme  Auscultationsbefund  nicht  mit  Ver- 
linderungen  des  Percussionsergebnisses  vergesellschaftet  ist ; deun  in  keinem  unserer 
Fiille  war  eine  auflfallende  Dlimpfung  liber  der  rechten  Fossa  supraspinata  zu  constatiren. 

Es  scheint  nicht  schwer,  bei  Beriicksichtigung  der  eben  geschilderten  Sachlage,  diese 
Verlinderungen  des  Lungenbefundes,  die  wir  in  einer  nicht  unbetr'achtlichen  Zalil  von 
Fiillen  zu  beobachten  Gelegenheit  hatten,  auf  ihre  Ursache  zuriickzufiihren,  und  wir 
glauben  nicht  lehlzugehen,  wenn  wir  die  scheinbar  catarrhalischen  Erscheinungen  von 
einem  durch  die  htiufigen  starken  Exspirationsstbsse  bewirkten  leichteren  Grad  von 
Atelektasenbildung  oder  Collaps  der  einzelnen,  wegen  ihrer  geringen  Ausdehnungs-  • 
flihigkeit  dazu  besonders  disponirten  Theile  des  Lungengewebes,  nlimlich  der  Spitzen, 
ableiten.  Je  Linger  die  Einwirkung  der  forcirten  Exspirationen  dauert,  desto  stirrkere 
Ausbildung  erflihrt  der  Lungencollaps,  desto  ausgeprligter  ist  die  Abschwlichung  des 
Athmens  und  das  subcrepitirende  Rasseln;  je  bfter  und  je  tiefer  spontan  geathmet 
wurde,  desto  mehr  entfalteten  sich  die  collabirten  Partieen.  Dass  aueh  diese  Folge- 
erscheinung des  heftigen  Hustens  diagnostische  Schwierigkeiten  mit  sich  f iihren  muss, 
liegt  auf  der  Hand,  und  wir  miissen  dies  auch  bei  Erbrterung  der  Diagnose  beriick- 
sichtigen. 

Wir  haben  nun  nach  der  Sc.hilderung  des  klinischen  Bildes  noch  der  Aetiologie  und 
Pathogenese  des  nervosen  Hustens,  wie  diese  sich  auf  Grund  unseres  uber  dreissig  Fiille 
umfassenden  Beobachtungsmaterials  ergiebt,  einige  Worte  zu  widmeu.  Die  Eut- 
stehung  des  Leidens  ist  in  alien  Fiillen  auf  einen  acuten  Larynx-,  Pharynx-  oder 


138 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Tracheal  catarrh  zuruekzufuhren  ; denn  von  alien  Patienten  wird  ubereinstimmend 
angegeben,  dass  der  Husten  von  einer  lieftigen  Erkaltung,  einem  Schnupfen,  einer 
Halsentzlindung  etc.  herdatire  und  stets  an  Intensitat  zugenommen  habe,  uni  nicht 
niehr  zu  verschwinden.  Wie  haben  wir  uns  nun  das  Bestehenbleiben  des  Hustens  als 
einzigen  Syraptomes  der  frliheren  Erkrankung  zu  erklaren  ? Doch  wohl  durch  die 
Annahrae,  dass  nach  dem  Verschwinden  der  nrspriinglich  als  Reiz  Oder  doch  als  reiz- 
verstiirkeudes  Moment  wirkenden  Schleimhautaffection  in  den  reflexverinittelnden 
Bahnen  ein  Zustand  gesteigerter  Erregbarkeit  zuriickgeblieben  sei,  der  den  Mechanismus 
der  Hustenbewegungen  schon  bei  verhaltnissmassig  geringen,  bei  unternormalen  Reizen 
in  Function  treten  lasst.  Aber  diese  Erhiihung  der  Reflexerregbarkeit  allein  geniigt 
nicht,  das  Phanomen  zn  erklaren  ; wir  miissen  auch  eine  directe  Hyperasthesie  in 
denjenigen  Theilen  der  Centralorgane,  in  welchen  die  aus  den  oberen  Theilen  des 
Athmuugsapparates,  aus  Larynx  und  Pharynx  zugefiihrten  sensiblen  Impulse  zum 
Bewusstsein  kommen,  also  eine  Ueberempfindlichkeit  der  Hirnrinde  annehmen,  denn 
die  grosse  Mehrzahl  der  Patienten  giebt  an,  dass  sie  ein  bestiindiges  Kitzeln,  DriAcken 
oder  Ziehen  in  der  Kehlkopfgegend  empfinde,  welches  sie  zum  Husten  zwingt.  Unsere 
Annahme,  dass  es  sich  am  eine  gesteigerte  Perceptionsfiihigkeit  und  urn  eine  vermin- 
derte  Hemmungsfahigkeit  von  Seiten  des  Willens  und  nicht  bloss  um  eine  erhiihte 
Reizbarkeit  der  periplieren  End-  oder  der  Reflexapparate  handelt,  wird  vor  Allem 
dadurch  bewiesen,  dass  bei  Nacht  die  Hustenanfalle  ausbleiben,  und  wesentlich 
gestutzt  durch  die  Thatsache,  dass  es  miiglich  ist,  bei  energischer  Willensanstrengung 
die  Anfalle  zu  unterdriicken.  Wiirde  es  sich  um  eine  blosse  Steigerung  der  Reflex- 
erregbarkeit, oder  um  eine  Vermehrung  des  Hustenreizes  (Schleimsecretion,  Gewebs- 
veranderungen  etc.)  handeln,  so  miissten  die  Anfalle,  wie  bei  anderen  Formen  des 
Hustens,  auch  in  der  Nacht  auftreten  und  den  Schlafenden  erweeken,  oder  auch  wah- 
rend  des  Schlafes,  ohne  dem  Kranken  zum  Bewusstsein  zu  kommen,  sich  abspielen. 

Wir  finden  ja  ahnliche  centrale  Reizungszustande  auch  an  anderen  reflectoriseh 
arbeitenden  Apparaten  ; so  ist  z.  B.  das  nach  Blasen-  und  Mastdarmaffectionen  zuriick- 
bleibende,  so  liistige  Gef  iihl  des  Tenesmus  auf  dieselbe  Ursache  zuriickzuf  iihren,  da  es 
nur  im  wachen  Zustande  besteht  und  durch  energische  Willensanstrengung  ebenso  zu 
unterdriicken  ist,  wie  das  sogenaunte  “ Leerschlucken,”  welches  nach  Rachencatarrhen 
zuriickbleibt  und  durch  eine  unangenehme  Empflndung,  die  nach  dem  Pharynx  pro- 
jicirt  wird,  bedingt  ist.  In  manchen  Fallen  spielen  wohl  beide  Vorgiinge,  eine  abnorme 
Reizempfanglichkeit  der  afficirt  gewesenen  Endapparate  und  eine  erhiihte  Erregbarkeit 
der  centralen  Partieen  bei  dem  Zustandekommen  der  Hustenparoxysmen,  resp.  der 
anderen  abnormen  Reflexerscheinungen,  eine  Rolle,  obwohl  der  psychische  Factor  vor- 
waltet,  wie  man  aus  dem  Umstande  ersehen  kann,  dass  die  Kranken  zu  husten 
anfaugen,  sobald  ihre  Aufmerksamkeit  auf  ihr  Leiden  hingelenkt  wird.  Zum  Zustaude- 
kommen  des  nerviisen  Hustens  ist  eine  nervdse  Disposition  durchaus  nicht  erforderlieb, 
da  eine  Reihe  unserer  Patienten  kaum  in  die  Categorie  der  neuropathischen  Individuen 
einrangirt  werden  kann,  da  namentlich  den  meisten  der  von  uns  beobachteten  Kiuder 
das  Priidicat  “ nervds  ” nicht  zukomrat ; jedoch  muss  hervorgehoben  werden,  dass 
“ Nervositat”  die  In-  und  Extensitat  der  Anfalle  begiiustigt  und  dass  bei  Kindem 
und  manchen  erwachsenen  Personen  in  der  Ausbildung  und  Entwickelung  der  starken 
Hustenparoxysmen  zweifellos  ein  Factor  eine  Rolle  spielt,  der  auch  sonst  nicht  seiten 
die  Ursache  von  Ivlagen  ist,  namlich  der  Eindruck,  den  das  Leiden  auf  die  Umgebuug 
macht.  Man  kann  im  Allgemeinen  annehmen,  dass  sich  bei  Kindern  und  bei  Erwach- 
senen die  Anfalle  um  so  mehr  steigern,  je  nachsichtiger  die  Angehdrigen  sind,  je  mehr 
Mitleid  der  Zustand  der  kleinen  und  bisweilen  auch  grossen  Kranken  erregt.  Wir 
kommen  bei  der  Therapie  auf  diesen  Puukt  zuriick,  da  er  fur  eine  rationelle  Behaud- 
lung  von  grdsster  Wichtigkeit  ist. 

Die  Diagnose  ist  sehr  leicht  bei  Beurtheilung  der  zur  zweiten  Categorie,  zur  Gruppe 


SECTION  XIII — LARYNGOLOGY. 


139 


der  “h'dsteluden,”  gehorenden  Falle,  und  man  kann  bier  sofort,  nachdem  die  Local  - 
unlersuchung  keine  Anhaltspunkte  fur  eine  locale  G-ewebsstiirung  gegeben  hat,  aus  den 
ansseren  Merkmalen,  die  die  ununterbrochen  biisteluden  und  rauspernden  Patienten 
gewiihren,  seine  Schliisse  zieben.  In  den  Fallen  von  explosivem  Husten  fiilireu 
1'olgende  Criterien  zur  Annabme  der  nervbsen  Form.  1)  Negativer  Localbefund  trotz 
laugeren  Bestehens  der  Affection.  2)  Feblen  der  Expectoration.  3)  Aufhbren  der 
Anfalle  wahrend  der  Nacht  und  bei  Ablenkung  der  Aufmerksamkeit.  4)  Auffallend 
geringes  Ergriffeusein  des  Patienten  nacb  anscbeinend  sebr  schweren  Anf'alleu. 
5)  Erfolg  der  Therapie,  die  keine  medicamentbse,  sondern  eine  psychische  ist. 

In  Fallen,  die  bereits  liingere  Zeit  besteben,  ist  schon  die  Abwesenheit  einer 
Gewebsstbrung,  das  Feblen  sonstiger  secundarer  und  das  Vorhandensein  von  Symp- 
tomen  allgemeiner  Nervositat  zur  Begriindung  der  Diagnose  geniigend.  Gelingt  es, 
die  Patienten  wabrend  eines  Anlalles  zu  beobacbten  und  das  oben  geschilderte,  fur  den 
nervbsen  Husten  characteristische  typische  Verbal  ten  des  Thorax  zu  constatiren  oder 
den  oben  erwahnten  Larynxbefund  zu  erbeben,  so  ist  die  Diagnose  gesichert. 

Schwerer  wird  die  Beurtheilung  des  Falles,  wenn  das  Krankbeitsbild  durch  die 
Folgeerscbeinungen,  deren  wir  bereits  bei  der  Schilderung  der  Symptome  Erw'ahnung 
gethan  haben,  sicb  complicirt,  wenn  sicb  die  anscheinenden  catarrbaliscben  Erschei- 
nungen  an  der  Lunge  linden,  oder  wenn  die  durch  den  aubaltenden  Husten  bewirkte 
Reizung  der  Schleimhaut  zu  entzundlicben  Zustiinden  derselben  gef iibrt  hat.  Hier, 
namentlicb  im  letztgenannten  Falle,  erfordert  die  Pr'ufung  der  Sachlage  oft  langere 
Zeit.  Im  ersten  Falle  ist  von  Wichtigkeit  das  Fehlen  einer  ausgesprochenen  Diimpfung, 
die  Aenderung  des  Befundes  nacb  tiefen  Inspirationen,  welche  norm  ale  Verh'altnisse 
herbeifuhren,  das  Fehlen  aller  sonst  auf  tiefere  Veranderungen  in  den  Lungen  zu 
beziehenden  Erscheinungen,  wie  z.  B.  der  Nachtschweisse,  der  Abmagerung,  der 
I characteristiscben  Sputa  ; im  zweiten  Falle  muss  bei  Stellung  der  Diagnose  ebenfalls 
die  Art  und  Dauer  des  Verlaufs  der  einzelnen  Anfalle,  die  Anamnese,  genau  gepr'uft 
und  ein  sorgfiiltiger  Localbefund  erhoben  werden  ; ausscblaggebend  fur  die  Diagnose 
•i  ist  aber  erst  der  Erfolg  einer  bestimmten  Therapie.  Wenn  es  gelingt,  trotz  der  langen 
Dauer  der  Erkrankung,  ohne  jede  topische  Behandlung  allein  durch  Unterdriickung 
der  Hustenanfalle,  ohne  Medicamente  oder  wenigstens  ohne  reichlichere  Auwendung 
von  Narcoticis  eine  Besserung  oder  Heilung  herbeizuf  iihren,  wenn  man  also  den  Beweis 
liefern  kann,  dass  nur  der  mechanische  Akt"  des  Hustens  allein  die  Ursache  der  Scbleim- 
hautaffection,  und  dass  der  Husten  das  primare,  die  Texturerkrankung  das  secundare 
Moment  sei,  so  ist  es  moglich,  den  Fall  richtig  zu  classificiren.  Dies  ist  aber  so  schwer 
und  erfordert  eine  solcbe  Aufopferung  von  Seiten  des  Arztes  und  eine  solcbe  Willens- 
energie  von  Seiten  des  Patienten,  dass  es  nur  seiten  gelingt,  in  so  vorgeschrittenen 
Fallen  den  Beweis  fur  die  nervose  Natur  des  Leidens  in  der  von  uns  angedeuteten 
Weise  zu  erbringen. 

Der  Verlauf  des  nervbsen  Hustens  bietet  im  Allgemeinen  nichts  Characteristisches, 
da  dort,  wo  die  Hyperasthesie  einmal  Platz  gegriffen  hat,  ein  spontanes  Aufboren  der 
Anfalle  nur  dann  zur  Beobachtung  kommt,  wenn  eine  totale  Veranderung  der  ausseren 
Verh'altnisse,  in  denen  die  Patienten  leben,  vor  sich  geht,  oder  wenn  Ereignisse  ein- 
treten,  die  den  Kranken  gebieterisch  von  seinem  Leiden  ablenken.  Das  Leiden  kann 
trotz  aller  Behandlung,  aller  localen  Applicationen  und  allgemeinen  Maassnahtnen 
mehrere  Jahre  hindurch  bestehen,  ohne  eine  wesentliche  Verschlimmerung  zu  erfahren 
oder  die  Emahrung  und  den  allgemeinen  Zustand  des  Patienten,  abgesehen  von  einer 
gewissen  Steigerung  der  nervbsen  Erregbarkeit,  iiberhaupt  ungiinstig  zu  beeinflussen. 
Nicht  seiten  folgt  auf  eine  Periode  scheinbarer  Besserung,  auf  eine  Zeit  der  Remission 
der  Anfalle,  naeh  Gemiithsaufregungen  oder  grbsseren  kbrperlichen  und  geistigen 
Anstrengungen  eine  Periode,  in  der  die  Anfalle  sich  haufen  und  extensiver  werden  ; 
in  der  Mehrzahl  der  Falle  tritt  nach  mebrmonatlichem  Bestehen  der  Affection  eine 


140 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Abschwachung  der  Anfalle  ein  ; bei  noch  Lingerer  Dauer  des  Zustandes  bleibt  nur, 
wie  schon  oben  erwahnt,  jeues  monotone  Husten  und  Rauspern  zur'uck,  welches  den 
Kranken  und  oft  namentlicb  seine  Umgebung  zur  Verzweiflung  bringt.  Die  zweite 
Categorie  oder  Form  des  nervbsen  Hustens  ist  also  hier,  um  dies  noch  einmal  zu 
betonen,  oft  nichts  anderes,  als  das  Eudstadium  der  Erkrankung,  dessen  Dauer  eiue 
nicht  zu  ermessende  ist.  Die  Prognose  ist  in  diesem  Stadium  oder  bei  der  zweiten 
Form  des  nervbsen  Hustens  eiue  ungunstige,  da  es  nicht  mehr  gelingt,  die  Energie  des 
Patienten  derart  zu  heben,  dass  sie  im  Stande  ist,  den  so  lange  Zeit  hindurch  von 
einem  verhaltnissmassig  geriugen  Reize  in  extensive  Bewegung  versetzteu  Retlex- 
mechanismus  zu  hemrnen  oder  durch  Selbstiiberwindung  die  unangenehme,  qualende, 
in  den  Larynx  oder  Pharynx  versetzte  Sensation  zu  unterdriicken,  anstatt  sie  mit  will- 
kiirlichen  Hustenbewegungen  zu  beantworten. 

Die  Therapie  des  Leidens  muss  demnach  im  Wesentlichen  darauf  gerichtet  sein, 
die  Hyperasthesie  mbglichst  fruhzeitig  zu  beseitigen  und  den  unaufhbrlich  arbeiteuden 
Reflexapparat  in  Ruhe  zu  versetzen.  Durch  die  innerliche  Darreichung  der  gebriiuch- 
lichen  Narcotica,  Nervina,  Expectorantia  und  Sedativa  (Morphium,  Belladonna,  Hyos- 
cyamus,  die  Brompraparate,  Arsen  etc. ) erreicht  man  diesen  Zweck  aber  ebensowenig, 
wie  durch  die  locale  Application  adstringirender  oder  beruhigender  Medicamente; 
denn  wenn  sich  auch  nicht  leugnen  lasst,  dass  durch  eine  Reihe  der  gebrauchlichen 
Methoden  eine  scheinbare  Besserung  f iir  Stunden,  Tage  oder  Wochen  herbeigef iihrt 
wird,  so  handelt  es  sich  doch  nur  um  eine  Abschwachung  uud  Verminderung  der 
Anfalle : eine  vbllige  Intermission  wird  nie  erzielt  und  auf  die  Periode  scheinbarer 
oder  wirklicher  Remission  folgt  unmittelbar  ein  R'uckfall  von  wesentlich  gesteigerter 
Starke.  Wir  haben  diesen  geringen  Effect  aller  bei  den  Gewebsstorungen  so  wirk- 
samen  Maassnahmen  so  oft  zu  beo  bach  ten  Gelegenheit  gehabt,  wir  haben  so  viele  Fa  lie, 
die  alien  bekannten  Manipulationen  getrotzt  haben,  in  Behandlung  bekommen,  dass 
wir  von  ihrer  Nutzlosigkeit  uns  vbllig  uberzeugt  haben.  Auch  von  den  allgemeinen 
Maassnahmen  (kalten  Abreibungen,  Galvanisation,  B'adern)  haben  wir  keinen  dauem- 
den  Nutzen  gesehen  und  glauben  deshalb,  sowohl  mit  Riicksicht  auf  unsere  praktischen 
Erfabrungen  in  solchen  Fallen,  als  auf  Grund  der  sich  aus  der  Pathogenese  des  nervbsen 
Hustens  ergebenden  theoretischen  Erwaguugen,  dass  in  diesen  Fallen  nur  eine  einzige 
Therapie,  die  psychische,  sich  deswegen  empfiehlt,  weil  sie  allein  im  Stande  ist,  den 
causalen  Anforderungen  zu  geniigen,  weil  sie  das  Uebel  an  der  Wurzel  angreift ; unser 
hauptsiichliches  Streben  muss,  weuu  wir  das  Leideu  als  eiu  nervbses,  auf  einer  Ueber- 
empfindlichkeit  gewisser  Theile  des  nervbsen  Apparates  beruheudes  betrachten,  darauf 
gerichtet  sein,  diese  Hyperasthesie  zum  Yerschwinden  zu  bringen.  Kbuuen  wir  dies 
durch  Medicameute  oder  locale  intralaryngeale  oder  intrapharyngeale  Maassnahmen 
erreichen?  Wir  glauben,  dass  dies  unmbglich  ist,  uud  zwar  deshalb,  weil  jedes 
beruhigende,  narcotische  Mittel  zwar  im  Stande  ist,  den  Reiz  fur  eine  gewisse  Zeit 
unmerklich  zu  machen,  aber  nicht  verhindern  kann,  dass  uacli  dem  Ablaufe  der 
Narcose  die  Empfindlichkeit  in  womoglich  noch  gesteigertem  Maasse  zuriickkehrt 
Ebeusowenig  vermag  die  locale  Behandlung  wirksam  zu  sein,  da  sie  in  der  That  keinen 
Angriffspuukt  hat.  Welchen  Nutzen  kann  man  sich  von  Adstringentien  dort  ver- 
sprechen,  wo  keine  Entziindung,  keine  nachweisbare  Gewebsstbrung  mehr  besteht? 
Man  wende  nicht  ein,  dass  man  bei  den  auf  ahulicher  Basis  entstandenen,  z.  B.  nach 
Entziindungen  der  Blase  oder  des  Mastdarmes  zuruckgebliebeneu  Zustanden  der 
Hyperasthesie  durch  Adstringentien  manchmal  recht  erfreuliche  Resultate  erreiche ; 
denn  der  Versuch  ist  in  alien  diesen  Fallen  kein  reiuer  eindeutiger,  da  die  Application 
des  Medicamentes  auf  die  iiberemplindlicheu  Stellen  zugleich  mit  einer  energischeu 
meclianischen  Behandlung,  eben  durch  das  Eiuf  uhren  des  Instrumentes,  verkmipft  ist, 
und  von  dieser  wisseu  wir  ja,  dass  sie  recht  ha u fig  die  Ueberempfindlichkeit  der  kranken 
Partieen  abstumpft  uud  direct  heilend  wirkt.  Ware  man  im  Staude,  mit  nareotischen 


SECTION  XIII LARYNGOLOGY. 


141 


oder  beruhigenden  Mitteln  eine  wirlclich  dauernde  Herabsetzung  der  Erregbarkeit  ini 
Nervensystem.  hervorzurufen,  so  wiirde  maa  nicbt  nbthig  haben,  immer  neue  Mittel 
uud  Metbodeu  zu  ersinnen,  am  den  Neurasthenischen  und  Neuropathischen  Heilung  zu 
: verscbafl'en,  Metlioden,  die  im  Weseutlicben  dock  alle  nur  den  eiuen  Zvveck  haben  und 
nur  allein  dadurch  wirken  kdnnen,  dass  sie  die  Willenskraft  der  Patienteu  zu  beben 
und  ibre  Energie  zu  starken  versucben.  Hat  man  die  Ueberzeugung,  dass  nur  dieser 
Factor  der  Bebandlung  der  wirksame  ist  — und  diese  Ueberzeugung  ist  ja  jetzt  gliick- 
licherweise  allgemein  geworden — , so  muss  man  in  alien  Fallen,  in  denen  die  Willens- 
n schwache  die  Ursacbe  der  zu  beobachtenden  Symptome  ist,  bier  den  Hebei  ansetzen, 

| und  darf  sich  keine  Zeit  und  Mlibe  verdriesseu  lassen,  Das  zu  erreicben,  was  man  fur 
das  allein  Kicbtige  bait. 

Hat  man  sich  in  einem  Falle  durcb  sorgfaltige  Untersucbung  und  Beriicksicbtigung 
aller  in  Betracbt  kommenden  Momente  davon  iiberzeugt,  dass  eine  Form  des  nervdsen 
Hustens  vorliegt,  so  muss  man  die  eben  erwahnten  Principien  der  Bebandlung  adop- 
tiren  und  in  jeder  Weise  darauf  hinzuwirken  sucben,  dass  der  Patient  seine  Ueber- 
empfindlicbkeit  und  den  dadurch  bedingten  Hustenreiz  nach  Kraften  zu  unterdrucken 
versucbe. 

Diesen  Zwec-k  erreicbt  man  bei  Kindern  und  jUngeren  Personen  in  vielen  F'allen 
einfacb  dadurch,  dass  man  eine  scbmerzhal’te  oder  in  irgend  einer  Beziebung  unange- 
nehme  Maassnabme  in  Aussicbt  stellt.  Durcb  die  blosse  Drohung,  es  miisse  gescbnitten 
i oder  gebrannt  werden,  wird  bei  einzelnen  Personen  schon  eine  auffallend  scbnelle 
Veranderung  und  ein  Cessiren  der  Hustenanfalle  bervorgebracbt  ; in  manchen  Fallen 
wirkt  die  Ankiindigung,  dass  der  Patient  von  den  Angebdrigen  getrennt  und  in  eine 
Austalt  gebracbt  werden  miisste,  in  sebr  frappanter  Weise  reflexbemmend.  In  schweren 
Fiillen  geniigt  die  Application  des  faradiscben  Pinsels  am  Halse,  oder,  um  jeden  Ein- 
i wand  einer  localen  Einwirkung  auf  die  scbeinbar  erkrankten  Organe,  den  scbeinbaren 
Locus  affectus,  auszuscbliessen,  auf  die  Brust,  um  ein  sofortiges  Cessiren  der  Anfalle 
zu  bewirken  ; eine  mehr  als  dreimalige  Anwendung  des  Pinsels  bei  mehr  oder  weniger 
i betrachtlicher  Stromstarke  ist  in  keinem  Falle  zur  vijlligen  Heilung  erforderlich.  In 
zwei  sebr  schweren  und  langdauemden  Fallen  hat  die  Isolirung  der  kleinen  Patienten 
bei  gleichzeitiger  Anwendung  des  faradiscben  Pinsels  einen  sehr  schnellen,  dauernden 
Erfolg  gehabt. 

Was  die  Therapie  der  geschilderten  Krankheitszustande  bei  Erwachsenen  anbetrifift, 
i so  ist  die  Bebandlung  und  Heilung  der  Paroxysmen  bei  alleiniger  Anwendung  scbmerz- 
1 baft  wirkender  Metboden,  durcb  die  gewissermaassen  eine  “ Abgewobnung  ” erzielt 
werden  soil,  eine  bei  Weitem  scbwierigere,  und  wir  sind  in  den  meisten  Fiillen  genothigt 
gewesen,  von  einem  combinirten  Heilverfahren  Gebraucb  zu  macben. 

Bei  der  zweiten  Categorie  des  nervdsen  Hustens  haben  wir  uberhaupt  einen  wesent- 
licben  dauernden  Erfolg  nicht  zu  erzielen  vermocbt ; wohl  aber  haben  wir  vorziigliche 
Resultate  bei  der  ersten  und  bei  der  combinirten  Form  gesehen,  und  zwar  selbst  in 
Fallen,  die  Jahre  lang  alien  Medicamenten  und  localen  und  allgemeinen  Maassnabmen 
* getrotzt  batten.  Hier  mussen  alle  Mittel  in  Anwendung  gezogen  werden,  mit  denen 
man  auf  die  Psyche  des  Kranken  einwirken  kann,  da  die  auf  die  Abschreckung  des 
Kranken  binzielenden,  rein  durcb  die  Erregung  kdrperlicben  Scbmerzes  wirkenden 
Maassnabmen  bei  Erwachsenen,  namentlich  bei  Manuern  — bei  Frauen  ist  der  electriscbe 
Piusel  oft  wirksam  — ihren  Zvveck  vdllig  verfehlen  wiirdeu. 

Wir  haben  als  das  beste  folgendes  Verfahren  erprobt : Man  setze  dem  Patienten 
den  Mechanismus  des  Hustens  auseinander  und  mache  ihm  ldar,  dass  es  nur  darauf 
ankomme,  den  ibn  so  qualenden  Reiz  durch  Willensstarke  zu  unterdriicken,  dass  keine 
Behandlungsweise  von  Erfolg  sein  ldinne,  wenn  sie  nicbt  durch  den  guten  Willeu  des 
Kranken  unterstutzt  werde  ; dass  ein  lilngeres  Bestehen  des  Hustens  mit  Gefahr  f iir 
die  Lunge  verknlipft  sei  ; dass  er  scbliesslich  zu  Lungenblutungen,  Lungenleiden 


142 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


f iiliren  kijuue.  Dana  fordere  man  den  Kranken  auf,  recht  tief  Athem  zu  holen,  den 
Atheru  anzuhalten,  und  lasse  sicli  in  der  Ueberwacliung  dieser  Form  der  Lungen- 
gymnastik  durcli  die  stets  eintretenden  Hustenanfalle  nicht  irre  machen.  Je  energischer 
man  dem  Kranken  zuredet,  je  mehr  man  seine  Willensschwiiche  tadelt,  desto  mehr 
gelingt  es,  ikn  zur  temporiiren  Unterdruckung  des  Hastens  zu  bewegen.  1st  dies  ein- 
oder  das  andere  Mai  gelungen,  ohne  dass  darauf  eine  verdoppelte  Explosion  erfolgt,  so 
bat  man  scbou  Yiel  gewonnen,  denn  der  Kranke  f'angt  jetzt  an,  Vertrauen  zu  der  ihm 
Anfangs  befremdlichen  Metbode  und  aucli  Selbstvertrauen  zu  gewinnen.  Hat  man 
liingere  Zeit  diese  Uebungen  persiinlich  geleitet,  so  ordne  man  eine  Fortsetzung  dieser 
Maassnabmen  obne  Beaufsichtigung  von  Seiten  des  Arztes  oder  der  Angehorigen  des 
Kranken  an  und  fahre  iu  dieser  Behandlung,  die  bisweilen  eine  zwei-  bis  dreimalige 
persdnliche  Anwesenbeit  des  Arztes  bei  den  Uebungen  innerhalb  der  ersten  Tage 
erfordert,  so  lange  fort,  bis  der  Husten  Tag  und  Nacht  cessirt  bat.  So  leichteu  Ivaufes 
kommt  man  aber  in  der  Regel  nicht  fort,  denn  selbst  die  Patienten,  die  unter  der  Auf- 
sicbt  des  Arztes  bereits  recbt  sclibue  Resultate  in  der  Reflexkemmung  erreicbt  haben, 
sind  nicbt  im  Stande,  allein  und  unbeaufsichtigt  ibrem  miicktigen  langgewobnten 
Eeize  zu  widerstehen,  und  namentlich  die  Bekiimpfung  der  Hustenanfalle,  welche  sic-h 
einstellen,  wenn  der  Kranke  zur  Nachtrube  das  Bett  aufgesucbt  bat,  macbt  oft  trotz 
aller  Yersucbe  uniiberwindliche  Schwierigkeiten.  Die  Patienten,  welche  den  Arzt  mit 
den  besten  Hoffnungen  verlassen  baben,  kebren  am  andereu  Tage  verzweifelt  zu  ihm 
zur'iick,  um  ibm  mitzutheilen,  dass  der  Hustenreiz  bei  dem  Versucbe,  ihn  zu  unter- 
dr'ucken,  so  stark  sei,  dass  sie  zu  ersticken  f urchten  miissten,  wenn  sie  ibm  nicht  nach- 
gaben,  und  dass  sie  jeden  solcben  Versuch  mit  ungemein  verstarkten  Paroxysmen 
bezablen  miissten.  Hier  muss  die  Ueberredungskunst  und  Energie  des  Arztes  das 
Mbglichste  tbun  ; er  darf  mit  seinen  Ermabnungen  und  Anordnungen  nicbt  nach- 
lassen  ; er  muss  die  t'aglichen  Uebungen  vervielfachen  und  auch  bei  borizontaler  Lage 
die  gescbilderte  mit  der  Atbmungsgymnastik  treiben  lassen,  bis  der  Kranke  den  Reiz 
uberwunden  und  den  Reflexmechanismus  in  seiner  Gewalt  bat.  You  grossem  Vortbeil 
fiir  die  Erzielung  derartiger  Resultate  ist  es  aucb,  die  Patienten,  bei  denen  der  Ueber- 
gang  von  kalter  in  warme  Luft  die  Hustenparoxysmen  hervorruft,  die  Lungen- 
gymnastik  in  k'uhler  Aussentemperatur  oder  bei  gebffueten  Fenstern  und  in  der  Zug- 
luft  vornehmen  zu  lassen. 

So  anstrengend  diese  Art  der  Behandlung  fiir  Arzt  und  Patienten  ist,.  so  grosse 
Anspriiche  sie  an  beide  Theile  stellt,  so  lobnend  ist  sie,  vie  unsere  Erfolge  gelehrt 
haben  ; auf  ihre  energische  Durchfiihrung  ist  daber  das  Hauptgewieht  zu  legen,  und 
die  andereu  Formen  der  Medication,  die  sonst  in  Auwendung  gezogen  zu  werden 
pflegen  uud  je  nacb  der  Art  des  Falles  und  der  Individualitat  der  Patienten  iu  Anwen- 
dung  kommen  miissen, — oft  kann  der  Arzt  ja  ihr  Vertrauen  uud  die  nbtbige  Disciplin 
nur  auf  dem  Umwege  eines  mit  dem  Nimbus  de3  Geheimnissvollen  umkleideten 
Mittels  oder  einer  sinnfiilligen  Metbode  gewinnen  — sind  nur  als  die  Zierratben  zu 
betracbten,  die  den  festumrissenen  Rahmen  der  zielbewussten  metbodiscben  Discipli- 
nirung  schmiicken  uud  ibm  seine  Einfdrmigkeit  nehmen. 


SECTION  XIII — LARYNGOLOGY. 


143 


CLASSIFICATION  DES  MUSCLES  DE  L’ ORGANE  DE  LA  YOIX. 

CLASSIFICATION  OF  THE  MUSCLES  OF  THE  ORGAN  OF  THE  VOICE. 

KLASSIFIKATION  DER  MUSKELN  DES  STIMMORGANES. 

PAR  LE  DR.  MOURA. 

I.  DIVISIONS  ADOPTEES  PAR  LES  AUTEURS  CLASSIQUES. 

Les  muscles  du  larynx  out  fete  un  objet  d’ etudes  et  de  recherches  pour  beaucoup 
d’anatomistes  et  de  physiologistes,  taut  aucieus  que  modernes,  et  malgrfe  leurs  travaux 
et  leurs  ecrits,  malgre  leurs  experiences  in  anima  vili,  on  n’est  encore  fixe  ni  sur  le  nom- 
bre  de  ces  agents  moteurs,  ni  sur  la  veritable  fonction  de  la  plupart  d’entre  eux. 

Nous  essaierons  cependant  de  faire  quelque  lumiere  sur  ces  importantes  questions, 
en  consignant  ici  des  resultats  que  nous  out  fournis  nos  dissections  au  laboratoire  de 
l’ancien  Hotel-Dieu  et  nos  examens  laryngoscopiques  sur  l’homme  pendant  la  vie. 

Jalier  est  considere  comme  l’un  des  premiers  anatomistes  qui  ait  fait  connaitre  ces 
muscles.  Aprfes  lui  Fabrice  d’Aquapendente,  dont  j’ai  souvent  entendu  faire  l’eloge 
par  un  professeur  de  l’Ecole  de  Montpellier,  Estor,  pfere,  en  a donne  une  description 
plus  complete. 

Sans  nous  attarder  A citer  tous  ceux  qui  out  refait  cette  description,  disons  que  Bichat 
et  Magendie  apportferent  dans  cette  etude  un  nouveau  moyen  de  controle,  l’experimen- 
tation  physiologique,  et  que  l’invention  du  laryngoscope  a,  depuis  26  ans,  imprime  un 
tel  essor  a tous  les  probifemes  qui  se  rattachent  a la  thfeorie  de  la  voix  humaine  ciue, 
d’ici  A peu  de  temps,  nous  l’esperons,  l’anatomie  et  la  physiologie  de  l’organe  vocal 
laisseront  peu  de  chose  a connaitre. 

Afin  de  rendre  notre  exposition  plus  simple  et  la  plus  lucide  possible,  examinons 
quelles  sont  les  idees  qui  out  servi  de  base  aux  diverses  classifications  des  auteurs. 

La  premiere  division  dont  nous  avons  A parler  est  fondfee  sur  l’anatomie.  Les  mus- 
cles larynges  y sont  partages  en  deux  groupes  denommes  intrinseques  et  extrinseques , 
suivant  qu’ils  font  directement  ou  indirectement  partie  du  larynx,  suivant  qu’ils  sont 
infra  ou  extra  larynges. 

Une  seconde  division  plus  ancienne  repose  sur  le  role  physiologique  attribufe  aux 
faisc-eaux  musculaires.  Elle  comprend  egalement  deux  sections  selon  que  les  muscles 
ouvrent  ou  ferment  P orifice  de  la  glotte.  On  a obtenu  ainsi  deux  groupes  appeles  Pun 
dilatateur  et  l’autre  constricteur  de  la  glotte. 

Cette  division  ne  satisfaisant  pas  tous  le  monde,  on  a cru  la  remplacer  plus  savam- 
ment  et  plus  utilement  par  une  troisifeme,  celle  de  muscles  abductears  et  de  muscles 
addueteurs,  qualificatifs  dont  la  forme  est  seduisante,  plus  scientifique  et  moins  vul- 
gaire,  mais  qui  n’en  valent  gufere  mieux  comme  expression  et  comme  exactitude. 

Notre  savant  et  regrette  physiologiste  Beclard,  decede  le  9 Fevrier  dernier,  avait 
pense  qu’il  fallait  ranger  les  muscles  du  larynx  sous  les  deux  vocables  de  gloitiques  et 
vocaux,  suivant,  dit-il  “ que  les  uns  out  pour  role  d’eloigner  ou  de  rapprocher  les  lfevres 
de  la  glotte,  d’augmenter  ou  de  diminuer  cet  orifice  ; et  les  autres,  de  modifier  la  lon- 
gueur, la  tension  et  l’epaisseur  des  cordes  vocales  inferieures,  ” dans  le  dictionnaire  de 
Dechambre,  article  sur  les  fonctions  du  larynx,  page  568  et  suivant  par  Beclard. 

Avant  d’apprecier  la  valeur  de  ces  classifications,  quelques  considerations  phvsiolo- 
giques  sont  indispensables  sur  le  larynx  comme  organe  de  respiration  et  de  phonation. 

II.  LE  LARYNX,  ORGANE  DE  RESPIRATION. 

Comme  organe  de  Pappareil  respirateur  le  larynx  contient  un  orifice  appele  glotte 
qui  est  le  passage  le  plus  detroit  et  le  plus  important  du  canal  acriffere.  Ce  passage 
simule  une  porte-ecluse  A deux  vantaux  ; Pair  entre  et  sort  par  cette  porte  sans  inter- 


144 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ruption  tant  que  la  vie  existe  et  1' integrity  de  la  fonction  respiratoire  exige  qu’il  soit 
toujours  ouvei't  et  libre. 

Or,  les  deux  vautaux  ex6cutent  sans  discontinuer  un  mouvement  de  va  et-vient 
toutes  les  quatre  ou  cinq  secondes  ; le  degre  d’ouverture  dn  passage  varie  en  conse- 
quence de  quelques  millimetres  en  plus  ou  en  moins.  Ils  sont,  en  effet,  le  sifege  de  deux 
deplacements  contraires  et  opposes  qui  les  ecartent  et  les  rapprochent  sans  les  appliquer 
toutefois  l’un  contre  l’autre. 

Ces  vantaux  ne  sont  autre  chose  que  les  replis  ou  l&vres  de  la  glotte,  les  cordes  vocal es 
de  Ferrcin  dont  les  arytenoides  representent  les  chevilles.  Leur  ecartement  et  leur 
rapprochement,  quelque  exageres  qu’ils  soient,  n’ofifrent  aucun  inconvenient  dans  les 
conditions  de  la  respiration  calme  et  normale.  Ce  fait  tres  important  vient  de  ce  que 
l’alleeet  le  retour  de  ces  valvules  mobiles  s’operent  independamment  de  la  volonte,  et 
cette  independance  est  la  meilleure  garantie  de  la  regularite  du  mecanisme  de  l’acte 
de  la  respiration.  Quand  cette  volontd  intervient,  c’est  toujours  pour  maintenir  Pinte- 
grite  de  leurs  mouvements  rythmiques,  pour  faire  disparaitre  la  cause  ou  l’obstacle  qui 
les  ont  troubles. 

Ainsi,  ce  n’est  qu’accidentellement  que  les  bords  de  la  glotte,  autrement  dit  les 
vantaux  de  la  porte  ecluse,  se  trouvent  amenes  jusqu’au  contact  et  maintenus  en  cet 
etat ; l’orifice  etant  retreci  ou  ferine,  l’air  entre  et  sort  difficilement,  bruyamment 
comme  a travers  une  tente  de  porte  mal  jointe.  Nous  n’avons  pas  a nous  occuper  de  ce 
sujet  en  ce  moment,  pas  plus  que  de  l’interruption  volontaire  ou  simulee  de  son  ecou- 
lement. 

Constatons  seulement : 

1.  Que  l’ecartement  et  le  rapprochement  alternatifs  des  bords  de  la  glotte  sont  syn- 
chrones  avec  les  deux  actes  de  la  respiration,  savoir  : l’inspiration  et  l’expiration. 

2.  Qu’ils  s’ ex£cutent passivement,  automatiqueinent,  c’est-a-dire,  sans  que  la  volonte 
intervienne  contrairement  a l’opinion  de  nos  confreres  en  laryngologie  et  it  celle  des 
physiologistes  en  general.* 

Malgaigne  dont  l’esprit  paralysait  la  main,  s’etait  occupe  de  la  voix  humain  dans 
un  travail  inser6  dans  les  archives  generates  de  medecine  en  1831.  De  ses  experiences 
et  de  ses  appreciations  plus  ou  moins  justes  il  avait  conclu  : 

“ Que  le  thyreo-arytenoidien  est  le  muscle  vocal  par  excellence,  tandis  que  les  autres 
ne  sont  que  des  muscles  respirateurs  ; qu’il  obeit  seul  il  la  volonte  et  que  les  autres. 
quoique  soumis  aussi  a la  volonte,  peuvent  agir  en  son  absence,  propriete  commune  a 
tous  les  respirateurs.  ” Tome  xxv. 

E.  Fournie  n’est  pas  du  tout  de  son  avis. 

‘ ‘ Contrairement  a son  assertion,  dit-il,  nous  pensons  que  le  muscle  thyreo-aryteuoi- 
dien  est  un  muscle  respirateur  au  merne  titre,  sinon  plus,  que  les  autres.  Si,  pendant 
l’inspiration,  la  glotte  s’agrandit  sous  l’influence  des  crico-arytenoidiens  posterieurs. 
elle  se  retrecit  pendant  l’expiration  et  ce  retrecissement  ne  peut  etre  effectue  que  par  les 
thyreo-arytenoidiens.  ” “ Physiologie  de  la  V oix  et  de  la  Parole,  ’ ’ page  406,  anuee  1 866. 

“Pendant  la  respiration  ces  muscles  (les  crico-aryt6noidiens  posterieurs)  sont  dila- 
tateurs  de  la  glotte.”  Id.  page  416. 

Mandl  considerait  ce  double  mouvement  rythmique  des  bords  de  la  glotte  comme 
accidentel  et  caracterisant  une  respiration  anormale,  c’est-il-dire,  acceleree  par  une  cause 
passagerc.  Dans  la  respiration  calme,  tranquille,  autrement  dite  normale,  les  bords  de 
la  glotte,  suivant  lui,  restent  fixes  et  immobiles.  Yoici  ce  qn’il  6crit  dans  son  “ Traite 
des  Maladies  du  Larynx,  p.  245,  publie  en  1872. 


* Notre  mani6re  do  voir  sur  co  point  do  la  physiologic  larvngfie  a 6t6  d6jil  exposfie  dans  notre 
mf“moiro  sur  la  nouvelle  Thgorio  do  la  voix,  pr6sent6  S,  l’Acadfimio  do  Medecine,  le  29  Mars 
1887. 


SECTION  XIII — LARYNGOLOGY. 


145 


“ Par  1’inspiratiou,  les  lfevres  vocales  sont  ecartees  et  partiellement  cachees  sous  les 
replis  superieurs  ; et  cet  ecartement  est  plus  ou  nioins  considerable  suivant  l’action  des 
' muscles  crieo-arytenokliens  posterieurs.  Si  ces  muscles  se  contraetent  et  si  leur  action 
jst  eoutre-balancee  en  partie  par  celle  des  crico-arytenoidiens  lateraux,  l’orifice  glottique 
presente  un  triangle  isoscele  la  base  duquel  serait  ajoute  un  autre  triangle  plus  petit, 
I sominet  tronque.  Si,  au  contraire,  1’iuspiration  est  tres  ample,  tres  profonde,  les 
muscles  crico-arytenoidiens  posterieurs  se  contraetent  d’uue  maniere  energique,  etc.” 
I— Alin<?a  248. 

“ Tous  les  muscles  intrinseques  sont  en  activity  tll’exception  des  thyro-arytenoidiens 
internes,  car  on  ne  voit  pas  les  levres  vocales  s’epaissir,  et  a l’exception  des  crico-thyro'i- 
diens.” — Id.  p.  249,  Alinea  282. 

La  fa5on  d’ecrire  de  Mandl  ferait  croire  qu’il  ne  possedait  pas  bien  la  langue  fran- 
4 (jaise. 

Au  commencement  de  la  page  245,  il  dit  que  l’immobilite  des  levres  de  la  glotte 
pendant  la  respiration  est  Vet  at  normal;  et,  dans  les  alineas  suivauts,  il  attribut  le  peu 
d'dcart  clout  dies  sont  le  siege  pendant  cette  meme  respiration  normale,  tranquille  et 
calme  est  dil  une  action  partielle  des  crico-arytdnoidiens  postdrieurs. 

“ Lorsque  l’inspiration  s’accomplit  normalement,  sans  effort  et  tranquillement,  les 
replis  inferieurs  conservent  une  immobility  presque  absolue  pendant  l’inspiration  et  l’ex- 
piration.” — Alinea  247,  p.  245. 

“ Pendant  l’expiration,  on  voit  les  replis  inferieurs  (apres  une  inspiration  tres  ample 
; et  profonde)  se  rapprocher  et  limiter  un  triangle  isoscele,  jusqu’d  ce  que  la  respiration 
\ normale  se  trouve  completement  etablie,  avec  une  immobility  complete  de  ces  replis.  ” — 
Alinea  248,  p.  245. 

C’est  il  tort,  selon  nous,  que  l’on  attribue  aux  muscles  intrinseques  larynges  une 
; part  quelconque  que  dans  les  deplacements  qu’eprouvent  les  bords  de  la  glotte  pendant 
les  deux  actes  de  la  respiration  calme  et  tranquille,  c’est-il-dire  normale. 

Mandl  commet  une  autre  erreur  quand  il  affirme  que,  pendant  la  respiration  calme 
i et  tranquille,  les  levres  vocales  restent  iminobiles  et  qu’elles  n’eprouvent  des  deplace- 
ments, des  oscillations,  qu ’accidentellement  et  volontairement. 

Les  oscillations  des  bords  de  la  glotte  sont  plus  ou  moins  visibles  chez  les  sujets  que 
l’on  inspecte.  La  cavite  du  larynx,  pour  un  grand  nombre  d’entr’eux,  n’est  pas  acces- 
1 sible  il  l’eclairage;  la  conformation  de  l’epiglotte  est  un  obstacle  des  plus  ordinaires,  et, 
quant  elle  permet  l’examen,  la  moitie  anterieure  de  l’orifice  glottique  reste  souvent 
invisible. 

Mais  lit  oil  cette  orifice  est  reproduit  en  entier  par  le  miroir,  ses  bords  executent  des 
allees  et  des  venues  regulieres  qui  sont  d’autant  plus  apparentes  que  la  glotte  est  plus 
I petite,  d’autant  moins  saisissables  et  etendues  que  levres  vocales  sont  plus  longues.  Ces 
f deplacements  rythmiques  varient  aussi  suivant  que  le  developpement  de  la  glotte  est 
: ou  n’est  pas  en  rapport  avec  le  diametre  du  porte-vent  (trachee)  et  la  capacity  du  souf- 
flet  pulmonaire.  Quelque  limites  que  soient  d’ailleurs  l’ecartement  et  le  rapproche- 
ment des  apophyses  vocales  pendant  l’inspiration  et  l’expiration,  nous  n’avons  jamais, 

I quant  a nous,  constate  leur  immobility  complete,  sauf  intervention  de  la  volonte. 

Lorsque,  pour  une  cause  ou  pour  une  autre,  le  rythme  de  la  respiration  tranquille 
' devient  rapide,  les  oscillations  des  lfevres  de  la  glotte  sont  aussi  plus  accentuees,  plus 
; frequentes,  car  l’acceleration  des  mouvements  respiratoires  se  reproduit  dans  ceux  des 
bords  de  la  glotte.  L’inspiration  £tant  plus  ample,  plus  profonde  et  plus  courte,  l’air 
aspire  entre  avec  force,  avec  precipitation  ; la  pression  qu’il  exerce  contre  les  parois  du 
conduit  vestibulaire  refoule  les  parties  non  resistantes  et  agrandit  d’autant  le  passage  de 
la  porte-ecluse  en  ecartant  ses  deux  vantaux. 

Quoique  plus  frequente,  la  respiration  n’en  est  pas  moins  facile  ; elle  a lieu  comme 
h l’etat  normal  et  sans  que  les  muscles  intrinseques  aieut  besoins  d’intervenir.  Il  n’en 
Vol.  iv— 10 


146 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


est  pas  de  meme  si  un  corps  etranger  ou  une  cause  pathologique  arrete  ce  mouvement 
rytlimicjue  et  occasiouueut  le  spasme  ou  la  stenose  de  la  glotte;  les  muscles  intrinseques 
eutrent  alors  en  actiou  pour  faire  disparaitre  1 ’obstacle  et  ouvrir  les  deux  vautaux  avec 
6nergie. 

Mais  tant  que  la  respiration  s’accompl it  dans  les  conditions  ordinaires  et  physiolo- 
giques  de  la  saute,  qu’elle  soit  lente,  qu’elle  soit  acceleree,  le  mouvement  oscillatoire 
des  bords  de  la  glotte  reste  involontaire , automatique,  organique,  ou  passif.  Cet  automa- 
tisme  est  du  reste  demontre  physiologiquement  par  les  experiences  des  vivisecteurs  et 
cliniquemeut  par  le  laryngoscope  chez  les  hysteriques  et  certaius  paralytiques. 

III.  LES  OSCILLATIONS  GLOTTIQUES  RESPIRATOIRES. 

Dans  la  “ Pliysiologie  Medicale  de  1’ Encyclopedic  ” de  Bayle,  Tome  v.,  1836,  Bra- 
cket s’exprime  ainsi  : 

“ La  section  des  recurrents  annule  la  voix  et  produit  le  serrement  de  la  glotte,  tan- 
dis  que  P experience  faite  sur  les  nerfs  larynges  superieurs  donne  lieu  l’aphonie  avec 
dilatation  de  l’ouverture  ; c’est  sans  doute  la  difference  de  ces  effets  qui  faisait  dire  a 
Magendie  et  i\  Ricberand  que  les  recurrents  se  distribuaient  aux  dilatateurs  de  la  glotte 
et  que  les  nerfs  larynges  superieurs  sont  destines  aux  muscles  aryteno'idiens  et  aux 
crico-tkyro'kliens,  Bichat,  Bayer,  Javard  n’admettent  aucune  distinction  entre  les  mus- 
cles qui  reijoivent  leurs  filets  nerveux  du  larynge  superieur  et  les  muscles  auxquels  sont 
destines  les  ramifications  des  recurreuts.  ’ ’ 

Le  grand  physiologiste  Claude  Bernard  a fait  plus  que  Bichat,  Magendie,  Longet  et 
autres.  II  a non  seulement  sectionne  le  nerf  spinal,  il  l’a  aussi  arrache  it  son  origine. 
Et  qu’a-t-il  oberve?  Vaphonie  complete  et  V integrity  des  mouvements  respiratoires. 

Or,  nous  savons  tous  que  le  spinal  se  distribue  ou  plutot  apporte  la  coutractilite  aux 
muscles  intrinseques  du  larynx  et  non  aux  muscles  extrinseques.*  Nous  savons  encore 
que  le  nerf  pneumogastrique,  son  voisin  d’origine,  tient  sous  sa  dependance  la  fonction 
respiratoire  et  que  la  glotte,  malgre  l’absenee  de  l’action  du  spinal,  continue  a s’elargir 
pour  le  passage  de  l’air  inspire  et  if  se  retrecir  pour  celui  de  Pair  expire. 

“Les  animaux  chez  qui  (sic.)  ou  a coupe  les  nerfs  spinaux, — ‘Robin  et  Littre, 
Diet,  de  Med.,  de  Ckir.  et  de  Pharm.,’  treizieme  edit.,  1873 — survivent  indefiniment 
et  l’on  n’a  observe  chez  eux  que  l’aphonie  ; les  autres  phenomenes  de  la  digestion,  de 
la  circulation  et  de  la  respiration  qui  sont  sous  l’influence  motrice  du  pneumo-gastrique 
ne  sont  point  paralyses  et  contiuuent  de  s’executer  normalement .” 

“ Le  larynx  constituant  un  appareil  double  destine  h la  fois,  a la  respiration  et  la 
phonation,  est  influence  par  deux  ordres  de  nerfs  distincts,  savoir:  le  pneumo-gastrique 
qui  preside  aux  mouvements  respiratoires  involonlaires  et  le  spinal  qui  preside  aux  mouve- 
ments  vocaux  volontaires.” — Id. 

“ Pendant  le  sommeil  le  larynx  ne  serf  qu’;\  la  respiration  et  ne  fonctionne  que  sous 
l’influence  du  pneumo-gastrique.  A l’etat  de  veille,  lors  de  l’acte  de  la  phonation, 
l’influence  du  nerf  spinal  intervient  pour  agir  sur  le  larynx.” — Id. 

Voyons  ce  que  dit  la  clinique  laryng£e  : 

Nous  avous  observe  sur  plusieurs  hysteriques  dont  la  voix  6tait  perdue  et  dont  la 
glotte  restait  entitlement  libre,  la  persistance  des  oscillations  des  bords  de  la  glotte  pen- 
dant l’inspiration  et  l’expiratiou  ; l’orifice  s’agrandissait  et  se  retr^cissait  alternative- 
ment.  Lorsque  ces  oscillations  manquent  et  que  les  bords  de  la  glotte  sont  immobiles, 
il  y a suppression  de  l’induence  motrice  du  pneumo-gastrique  et  du  spinal  en  meme 
temps. 

Nous  avons  retrouv6  ces  mouvements  rytkmiques  chez  deux  sujets  ages,  atteints  de 
ramollissement  cerebral  et  d’aphonie.  Quand  on  essayait  de  leur  faire  prononcer  les 


*!  Il  faut  exccptcr  le  pharyngien  inferiour. 


SECTION  XIII — LARYNGOLOGY. 


147 


voyelles  >}  ou  a les  bords  de  la  glotte  se  rapprochaient  avec  difficulty  et  un  peu  plus  que 
pendant  l’expiration,  mais  les  apophyses  vocales  ne  parvenaient  pas  it  se  rencontrer. 

Sur  un  malade  frappe  d’hemorrhagie  de  la  moelle  allongee,  la  lev  re  glottique  droite 
ex6eutait  ses  mouvements  comme  l’6tat  normal,  tandis  que  la  levre  gauche  flanide  et 
relach6e,  restait  6cartee,  immobile  en  dehors  pendant  l’inspiration  et  ne  revenait  seu- 
lement  en  dedans  pendant  l’expiration. 

Ainsi  la  physiologie  et  la  clinique  laryngee  confirment  l’independance  entre  les  mou- 
vements des  bords  de  la  glotte  au  moment  de  la  respiration  et  ceux  qu’ils  executent 
pendant  la  phonation.  II  n’est  pas  possible  d’attribuer  les  premiers  a l’influence  des 
muscles  intrinseques  du  larynx,  muscles  qui  appartiennent  exclusivement  a l’organe 
vocal  et  obeissent  aux  ordres  de  la  volonte.  Les  oscillations  des  bords  de  la  glotte  sont 
un  effet  de  la  motricite  organique  qui  leur  est  distribute  par  les  filets  du  pneumo-gas- 
trique,  nerf  involontaire  ou  de  la  vie  de  nutrition. 

Si  les  agents  intrinseques  ne  prennent  aucune  part  it  ces  deplacements  regulicrs  et 
symetriques,  il  n’en  est  pas  de  meme  des  muscles  extrinseques,  le  sterno-thyreo'idien 
par  exemple,  celui-ci  est  essentiellement  inspirateur ; il  a son  attache  fixe  en  bas,  en 
arriere  et  en  dedans,  sur  la  fourchette  sternale  ; son  attache  mobile  est  placee  entrant 
sur  les  cotes  du  cartilage  de  la  pomme  d’Adam,  immediatement  au  dessous  de  l’hyo- 
thyreoidien,  appele  aussi  thyreo-hyoidien. 

En  se  contractant  le  sterno-thyreo'idien  entraine  en  bas  le  cartilage  Adamique  pen- 
dant que  le  crico'ide  descend  lui-meme  et  suit  le  mouvement  de  la  traehee  qui  se  rac- 
courcit  de  quelques  millimetres.  Le  thyreo'ide  est  en  meme  temps  le  siege  d’un  depla- 
cement en  avant ; ses  petites  cornes  glissent  d’arriere  en  avant  sur  les  deux  facettes 
articulaires  crico'idiennes  par  suite  de  la  pression  qu’exerce  le  poids  de  la  colonne  d’air 
inspire  contre  les  bords  de  l’orifice  glottique  et  contre  l’angle  rentrant  du  cartilage, 
ainsi  que  nous  l’expliquons  plus  loin. 

Ce  changement  des  rapports  entre  le  thyreo'ide  et  le  crico'ide  est  tres  accessible  a 
l’exterieur  au  moyen  de  l’index  place  dans  l’intervalle  qui  les  separe  et  que  remplit  le 
fort  ligament  anterieur  thyreo-crico'idien.  Il  est  d’autant  plus  manifeste  que  l’inspira- 
tion est  plus  profonde.  Pendant  qu’il  se  produit,  un  autre  s’opere  il  l’interieur  dn 
larynx;  les  bords  de  la  glotte  sont  ecartes  et  l’orifice  s’agrandit  dans  ses  deux  diametres. 
Ce  changement  interne  ou  glottique  a lieu  passivement  avons-nous  dit,  c’est-h-dire  sans 
1’ intervention  des  muscles  intrinseques,  dit  vocaux  et  auxquels  on  a applique,  mal  h- 
propos  dans  cette  circonstance,  le  qualificatif  de  glottiques.  Il  a pour  causes  non  seule- 
ment  la  motricite  organique,  mais  aussi  la  pression  atmospherique. 

Au  moment,  en  effet,  oh  l’inspiration  commence,  le  soufflet  thoraco-pulmonaire  se 
dilate  ; il  produit  un  vide  dans  le  canal  aerif  ere  tout  entier.  L’air  exterieur  entre  avec 
precipitation  ; ne  trouvant  pas  un  passage  suffisant  il  travers  les  vantaux  de  la  porte- 
ecluse  du  canal,  il  pese  sur  eux  et  sur  l’angle  rentrant  du  cartilage  de  la  pomme  d’Adam 
de  tout  le  poids  d’une  colonne  atmospherique  equivalant  it  la  difference  des  deux  pres- 
sions  aeriennes  externes  et  internes.  Les  lev  res  de  la  glotte,  n’etant  pas  en  6 tat  de 
tension,  ne  resistent  que  par  leur  resistence  organique  ; elles  s’ecartent  et  le  passage 
s’ouvre  il  droite  et  ii  gauche  ; l’air  entre  sans  obstacle  et  produit  le  souffle  tracheal  si 
connu. 

Le  cartilage  Adamique  cedant  de  son  cote  il  cette  meme  pression  est  pousse  en  avant 
et  en  bas;  ses  petites  cornes  glissent  dans  le  meme  sens  sur  les  facettes  du  crico'ide  et 
l’orifice  de  la  glotte  s’allonge  d’arritire  en  avant.  Le  passage  se  trouve  ainsi  agrandi 
dans  toutes  ses  dimensions.  Pas  n’est  besoin,  on  le  voit,  de  faire  intervenir  l’action 
des  muscles  intrinseques  diastoliques  dilatateurs  pour  obtenir  cet  elargissernent. 

Comme  organe  de  l’appareil  respirateur,  le  larynx  est  le  siege  d’un  mouvement  de 
totalite  qui  determine  sa  descente  et  doit  le  faire  considerer  comme  uue  dependance  de 
la  traehee. 


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NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Quant  it  son  ascension  pendant  l’expiration,  elle  est  plus  passive  qu’active;  le  retour 
du  conduit  tracheal  it  sa  position  normale  de  repos  suffit  pour  la  produire. 

IV.  LE  LARYNX,  ORGANE  DE  PHONATION. 

Envisage  comrae  organe  de  l’appareil  phonateur  le  larynx  est  une  sorte  de  caisse 
sonore,  dans  laquelle  sout  disposers,  parallelement  et  symetriquement,  deux  anches 
membraneuses  qui  torment  l’embouchure  d’un  instrument  de  musique  ayant  la  plus 
grande  analogie  avec  celle  du  Basson.  Ces  deux  anches,  libres  seulement  it  leur  extre- 
mity ou  Lord  superieur,  ne  sont  point  rigides  ; elles  sont  elastiques  en  tout  sens,  c’est-a- 
dire  modifiables  dans  leurs  trois  dimensions  : longueur,  largeur,  epaisseur,  sans  altera- 
ration  de  leurs  Elements  anatomiques. 

L’anche  du  Basson  est  formiee  de  deux  languettes  accou pleas,  libres,  il  est  vrai,  sur 
deux  cot6s  eomme  it  leur  extremite  superieure.  Cette  anche  ne  possede  pas  l’avantage 
de  s’elargir,  ni  de  s’amincir,  defauts  qui  sont  compenses  par  les  nombreuses  variations 
de  longueur  qu’elle  peut  subir  dans  sa  partie  vibrante. 

Quant  it  l’anche  humaine,  ses  proprietes  61astiques  ne  sont  mises  en  jeu  que  dans 
des  limites  trks  restreintes.  Mais  d’autres  proprietes  physiques  et  organiques  donnent 
au  son  qu’engendrent  ses  vibrations  des  qualites  speciales  qui  le  rendent  inimitable  au 
moyen  des  instruments  de  fabrication  industrielle. 

Nous  retrouvons  ici  les  deux  vantaux  de  la  porte-ecluse  transformes  en  levres  et 
cordes  vocales  par  l’action  d’agents  moteurs  volontaires  qui  leur  communiquent  plu- 
sieurs  sortes  de  mouvements.  Le  passage  de  l’air  respire  subit  en  meme  temps,  dans 
ses  degres  d’ouverture,  des  modifications  profondes  qui  ont  pour  but  de  regler  la  sortie 
de  la  colonne  d’air  expulsee,  de  lui  conserver  l’energie  et  la  rapidite  necessaires  aux 
vibrations  de  l’anche  glottique. 

Ce  sont  ces  agents  diversement  appeles  : muscles  intrinseques  et  extrins&ques,  eonstric- 
teurs  et  dilatateurs,  adducteurs  et  abducteurs,  glottiquea  et  vocaux,  que  l’on  a cherche  it 
classer  tantot  anatomiquement,  tantot  physiologiquement  et  tantot  coniine  puissances 
respiratrices  et  phonetiques  it  la  fois. 

Nous  avons  dejit  dit  que  ces  classifications  etaient  insuffisantes  et  ne  repondaient  pas 
aux  besoins  de  la  science  laryngologique.  II  nous  semble  pourtant  possible  de  realiser 
ce  desideratum  en  donnant  pour  bases  it  la  nouvelle  classification  l’anatomie  et  la  phy- 
siologic reunies  et  pour  but  la  phonation. 

La  division  en  intrinseques  et  extrinsfeques  a le  grave  inconvenient  de  ne  rien  deter- 
miner ii  propos  des  changements  et  des  mouvements  que  les  muscles  larynges  impriment 
aux  levres  de  la  glotte  pour  en  fai re  l’anche  vocale  ; ce  fouctionnement  est  eependant 
sous  l’infiuence  des  muscles  intrinseques  ou  intra-larynges. 

Celle  de  constricteurs — mot  impropre — et  dilatateurs  s’adresse  aux  mouvements  qui 
relevent  i\  la  fois  de  la  pathologie,  de  la  respiration  et  de  la  phonation. 

La  division  en  adducteurs  et  abducteurs  ne  comprend  que  des  muscles  ayant  pour 
role  de  rapprocher  et  d’eloigner  les  bords  de  la  glotte;  comme  la  precedente  elle  ne  fait 
aucune  distinction  entre  les  mouvements  et  les  modifications  qui  s’y  produisent  pendant 
les  actes  de  la  respiration  et  de  la  phonation. 

La  classification  du  professeur  Beclard  en  glottiques  et  vocaux  est  une  tentative  faite 
vers  la  solution  scientifique.  On  reconnait  que  la  premiere  expression  se  rapporte,  dans 
l’esprit  du  classificateur,  au  fouctionnement  de  la  glotte  dans  l’acte  de  la  respiration,  et 
la  seconde  celui  des  muscles  dans  l’acte  phonateur;  mais  elles  reposent  sur  un  cerele 
vicieux,  car  les  muscles  vocaux  sont  glottiques  pendant  la  phonation,  c’est-;\-dire  modi- 
ficateurs  de  l’orifice  de  la  glotte;  en  outre  elles  ne  donnent  aucune  idee  des  changements 
de  forme  qui  s’opferent  dans  les  replis  de  la  glotte,  ni  des  divers  mouvements  dout  ils 
sont  le  sikge  malgre  les  explications  de  son  auteur. 


SECTION  XIII LARYNGOLOGY. 


149 


Eu  somme,  ces  essais  de  classification  n’ont  pas  fait  avancer  la  question  qui  preoc- 
cupe  tout  le  monde,  celle  de  la  theorie  de  la  voix. 

V.  DIVISIONS  FONDLES  SUE  L’ANATOMIE,  LA  PHYSIOLOGIE  ET  LA  PHONATION. 

Dans  notre  revue  clinique  des  laryngopathies , publie  en  1874,  nous  disions  au  cbapitre 
des  alterations  fouetionuelles,  page  85  : 

“ Corame  le  cceur,  le  larynx  (c’est-;\-dire  la  glotte)  jouit  de  deux  mouvements  con- 
traires,  la  contraction  et  la  dilatation.  Les  noms  de  systole  et  diastole  peuvent  done 
s’appliqner  il  chacun  d’eux.” 

“Les  cordes  vocales  jouissent  d’un  troisieme  mouvement  tout-ii-fait  different  et 
independant  de  ceux  de  rapprochement  et  d’ecartement  ; c’est  uu  mouvement  de  ten- 
sion proprement  dit.”  Ce  mouvement  se  produit  d’avant  en  arriere  alors  que  le  car- 
tilage thyreoidien  tout  fixe  par  les  muscles  elevateurs  laryngiens,  le  cricoide  est,  a son 
tour,  porte  en  liaut  par  les  thyreo-cricouliens. 

“ Uu  seul  mot  d’origine  grecque  exprime  ce  mouvement  d’avant  en  arriere  ; e’est 
l’adverbe  aip,  derive  lui-meme  de  la  preposition  an- v.  Les  noms  apstole  et  apstolique 
desigueront  en  consequence  et  qualifieront  la  tension  seule  (en  long)  des  cordes  vocales.” 

Yoici  maintenant  uu  extrait  de  notre  memoire  presente  a 1’ Academic  de  Medecine 
le  29  Mars,  1887,  sur  notre  theorie  de  la  voix. 

“ Les  physiologistes  qui  ont  considere  les  replis  de  la  glotte  comme  des  ligaments,  des 
rubans  ou  des  cordes  ont  admis  que  l’action  musculaire  avait  pour  effet  de  les  allonger 
seulemeut,  leur  communiquant  ainsi  la  tension  necessaire  il  remission  des  sens.” 

“ Ceux  qui,  au  contraire,  les  ont  regardes  comme  des  languettes  membraneuses,  des 
anches  ou  des  levres  ont  entendu  par  le  mot  tension  le  developpement  en  largeur  et  en 
longueur,  c’est-ii-dire  en  surface,  de  ces  replis  ; selon  eux,  les  muscles  intrinsisques  du 
larynx  produisent  il  la  fois  l’allongement  et  l’elargissement,  l’extension  en  un  mot  des 
levres  de  la  glotte.” 

“ C’est  bien  en  long  et  en  large  que  cette  tension  a lieu  en  effet.  L’observation 
laryngoscopique,  tout  en  canfirmant  le  fait,  a permis  de  l’analyser,  de  le  dedoubler  et 
de  reconnaitre  que  l’action  musculaire  qui  produit  la  tension  en  largeur  n’est  pas  la 
meme  qui  opere  l’allongement.  Ces  deux  especes  de  tensions  sont  dries  il  deux  rneca- 
nismes  physiologiques  differents.  Sous  le  nom  de  systole  ou  de  distension  nous  designons 
le  developpement  transversal  ou  en  surface  des  replis  de  la  glotte,  et  sous  celui  d’ apstole 
ou  tension  en  long  leur  allongement. 

Enfin,  dans  notre  memoire  sur  le  role  physiologique  du  muscle  arytenoidien,  communi- 
que il  la  Societe  Franchise  d’Otologie  et  de  Laryngologie,  session  d’Octobre,  1886,  nous 
nous  exprimons  ainsi,  il  propos  de  la  distribution  anatomique  et  physiologique  des  mus- 
cles intrinsfeques  : 

“Ces  agents  ont  6te  distribues  par  la  nature  sur  trois  plans  bien  distincts,  suivant 
le  role  que  les  faisceaux  musculaires  dont  ils  sont  formas  doivent  remplir  ; etc.” 

Le  premier  plan,  antdrieur , est  constitue  par  les  thyreo-cricouliens  dont  la  contrac- 
tion produit  l’allongement  d’avant  en  arribre  des  levres  de  la  glotte,  c’est-il-dire,  l’apstole; 
nous  l’avons  designe  en  consequence  par  le  qualificatif  d’ apstolique. 

Le  second  plan,  interne  ou  median,  comprend  les  crico-arytenoidiens  lateraux,  les 
thyreo-arytenoidiens  externes  et  internes,  muscles  qui  ont  pour  role  de  rapprocher  les 
levres  de  la  glotte  et  de  les  tendre  transversalement  c’est-il-dire  en  surface  ; ils  pro- 
duisent, en  un  mot,  la  systole  glottique  ou  laryngbe  et  doivent  etre  appeles  par  cela  meme 
plan  et  muscles  systoliques. 

Enfin,  le  troisieme  plan,  que  nous  avons  dit  posterieur  il  cause  de  la  situation  de  ses 
faisceaux  musculaires  en  arriere  du  larynx,  est  compose  de  l’aryt6noidien  et  des  crico- 
arytenoidiens  posterieurs  dont  le  role  est  d’ecarter  les  lfevres  vocales,  d’ouvrir  trausver- 
salement  la  glotte.  C’est  done  un  plan  musculaire  diastolique  ; il  effectue  la  dilatation 


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NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


de  1’orifice  ou  diastole  glottique,  c’est-ii-dire  le  relachement,  l’ecartement  de  ses 
bords. 

Dos  it  present  nous  pouvons  etablir  notre  classification  en  nous  servant  de  la  triple 
base  de  l’auatoraie,  de  la  physiologie  et  de  la  phonotion  ou  mieux  pkonologie,  et  en 
prenant  pour  point  de  depart  la  division  anatomique  foudamentale  de  nos  devanciers 
en  muscles  intrins&ques  de  intra-larynyds,  et  muscles  extrinsbques  ou  extra-larynges. 

VI.  CLASSIFICATION  PAR  LE  DR.  MOURA. 

La  premiere  classe,  que  nous  appelons  intrin-phontiques,  comprend  trots  ordres  d’a- 
gents  moteurs  vocaux,  savoir  : 

1°  Les  agents  systoliques,  dont  les  faisceaux  musculaires  ont  pour  role  de  fermer  it 
volonte  l’orifice  de  la  glotte. 

Cet  ordre  renferme  trois  groupes  ou  genres  : 

Le  premier,  que  nous  nommons  systoliques-addueteurs , rapproche  les  bords  de  la 
glotte  jusqu’au  contact,  les  deployant  et  en  faisant  deux  anches  prismatiques. 

Le  second,  que  nous  designons  sous  le  nom  de  systoliques  tenseurs,  tend  la  partie 
vibrante  des  anches,  la  diminue  ou  l’augmente  suivant  que  le  ton  de  la  gamme  ou  du 
registre  vocald  monte  ou  descend  lui-meme. 

Le  troisiiime,  denomme  systoliques-vcstibulaires,  regie  la  tension  des  parois  du  vesti- 
bule sus-glottique. 

2°  Les  agents  apstoliques,  dont  les  faisceaux  musculaires  ont  pour  role  d’effectuer  la 
tension  en  long,  c’est-il-dire  V allongement  d'avant  en  a r rib  re  des  bords  de  la  glotte  dejil 
transformes  en  prismes  par  les  systoliques-addueteurs  et  tendues  en  surface  par  les  systo- 
liques-tenseurs. 

Un  seul  groupe  compose  cette  ordre  ou  ce  plan  musculaire  ; nous  le  nommons  apsto- 
liques-tumeurs. 

3°  Les  agents  diastoliques,  dont  les  faisceaux  musculaires  ecartent  les  bords  de  la 
glotte,  dilatent  transversalement  et  it  volonte  son  orifice. 

Cet  ordre  comporte  deux  groupes  ou  genres  : 

Le  premier  appele  diastoliques-interligamentaires,  ouvre  la  partie  anterieure  ou  mem- 
braneuse  des  bords  de  la  glotte,  a volonte,  c’est-a-dire  activement ; il  produit  le  rela- 
chement des  l&vres  vocales. 

Le  second  a ete  nomine  diastoliques-interaryteno'idiens.  II  a pour  fonction  d’ouvrir, 
it  volonte,  la  partie  posterieure  ou  cartilagineuse  de  l’orifice  glottique. 

Quant  aux  agents  moteurs  extrinseques,  leur  action  commune  consiste  a aider  pko- 
netiquement  celle  des  agents  intrinseques,  en  elevant  ou  abaissant,  tantot  directement, 
tantot  indirectement  le  larynx,  et  contribuant  ainsi  it  produire  la  systole  ou  la  diastole, 
laryngee,  c’est-a-dire  il  fermer  ou  il  ouvrir  l’orifice  de  la  glotte. 

Une  seule  classe  compose  cette  grande  division  anatomique.  Nous  la  designons  sous 
le  nom  d’ extrinsbques- glottiques,  parce  que,  en  definitive,  les  nombreux  faisceaux  muscu- 
laires qui  entrent  ici  en  action  aboutissent,  au  point  de  vue  phonologique,  il  fermer  ou 
il  ouvrir  la  glotte. 

Cette  classe  comprend  deux  ordres,  savoir  : 

Le  premier,  appele  dltvateurs-systoliques,  effectue  l’ascension  du  larynx  et  le  retr6cis- 
sement  de  la  glotte.  Il  se  divise  en  deux  groupes  : 

L’un,  qualifie  de  direct,  parce  que  les  muscles  qui  en  font  partie  out  leurs  attaches 
mobiles  inserdes  sur  l’une  des  pieces  cartilagineuses  du  larynx,  tandis  que  leurs  attaches 
fixes  le  sont  sur  un  point  plus  ou  moins  61oigne  de  cet  organe. 

L’autre,  nomm6  indirect,  parce  que  les  agents  musculaires  qu’il  comprend  n’out 
aucune  de  leurs  insertions  sur  l’organe  vocal. 

Le  second  ordre  est  dit  abaisseurs  diastoliques;  ses  faisceaux  musculaires,  en  se  con- 


SECTION  XIII — LARYNGOLOGY. 


151 


tractant,  entrainent  la  descente  da  larynx  et  la  dilatation  transversale  de  la  glotte. 
Com  me  le  premier  il  comprend  deux  groupes  : 

L’un  et  l’autre  portent  les  noms  de  directs  et  indirects  par  les  memes  raisons  que 
nous  venons  de  faire  counaitre. 

Telle  est  la  classification  que  nous  soumettons  it  l’attention  de  l’academie.  Nous  en 
donnons  le  tableau  synoptique  avec  les  noms  des  agents  musculaires  qui  composent 
chaque  groupe.  Eu  terminant  ce  travail,  nous  ferons  remarquer  que  nous  avons  evite 
de  nous  servir  du  qualificatif  constricteur  de  la  glotte , parce  qu’il  convient  il  un  6 tat 
spasmodique  ou  pathologique  et  non  il  un  etat  physiologique  ou  normal  de  cet  orifice. 


CLASSIFICATION  DES  MUSCLES  DU  LARYNX. 


Divisions. 

Classes. 

Ordres. 

Groupes  ou  Genres. 

Faisceaux  Muscu- 
laires. 

Intrins£ques 

larynges. 

Phone- 
tiques  pro- 
duisant. 

La  systole 
laryngee  ou 
glottique. 

L’Apstole. 

La  diastole 
laryngee  ou 
glottique. 

f Systoliques. 

Adducteu'rs. 

I Systoliques. 
j Tenseurs. 

| Systoliques. 

[ Vestibulaires. 
Apstoliques-Ten- 
seurs. 

r Diastoliques. 

1 Ligaraentaires. 

1 Diastolique  Aryte- 
[ noidien. 

' Crico-Arytenoldiens. 
Lateraux. 

Thyreo-Arytenoldiens. 

Internes. 

Thyreo-Arytenoldiens. 

Externes. 

Thyreo-cricoldiens. 

Crico-Arytenoldiens. 

Posterieurs. 

Arytenoldien. 

Extrinseques 

larynges. 

Glottiques. 

Elevateurs. 

Systoliques. 

Abaisseurs. 

_ Diastoliques. 

( Directs. 

(Indirects. 

• 

< Directs. 
(Indirects. 

i 

Hy  o-Th  y reold  iens. 
Pliaryngien  inferieur. 
^haryngien  moyen. 
Muscles  Sus-Hyoldiens. 

Sterno-thyreoldiens. 

Scapulo-Hyoldiens. 

Sterno-Hyoldiens. 

LE  SULFURE  DE  CALCIUM  DANS  LE  TRAITEMENT  DE  LA 

DIPHTHERIE. 

SULPHURET  OF  LIME  IN  THE  TREATMENT  OF  DIPHTHERIA. 

DAS  SCHWEFELCALCIUM  IN  DER  BEHANDLUNG  DER  DIPHTHERIE. 

PAR  LE  DR.  F.  LABORDE  DE  WINTHUYSSEN, 

A Lebrija  (Sevilla)  Espagne. 

La  diphtherie  qui  dejoue  si  souvent  les  efforts  de  notre  art,  a droit  il  la  sp6ciale  atten- 
tion des  praticiens,  puisqu’a  son  caractere  infectieux  et  parfois  epidemique,  est  unie  sa 
frequence,  et  sa  presque  incurabilite. 

Les  etudes  baeterioscopiques  donneront,  sans  doute,  tot  ou  tard  la  clef  de  l’6nigme 
de  sa  pathogenie.  Aux  microbiologistes  done  l’honneur  de  la  recherche  et  la  gloire  de 
l’enquete,  et  pour  nous,  les  medecins  qui  ne  pouvont  pas  nous  vouer  il  ces  6tudes  le 
flatteur  espoir  d’obtenir,  un  beau  jour,  la  preuve  experimentale  de  sa  nature  micro- 
bienne. 

Si  nos  moyens  d’analyses  sont  encore  impuissants,  pour  dSceler  l’existence  du  germe, 
ou  virus  originaire  de  la  maladie,  nous  n’avons  quA  etre  il  l’attente  des  decouvertes,  et 


152 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


la  diphtherie,  dont  tous  les  caractferes  ( inoculation , transmission,  incubation,  etc.)  le  font 
ressembler,  aux  maladies  zymotiques  et  parasitaires,  aura  de  meme  son  microbe  spe- 
cifique,  on  nous  le  fera  connaitre,  nous  aboutirons  it  le  cultiver,  nous  arriverons  meme 
it  l’attenuer. 

C’est  du  moins  l’hypothfese  que  nous  nous  croyons  en  droit  de  soutenir,  it  juger  par 
l’etude  pratique  de  la  maladie,  dont  le3  differentes  formes,  ne  seront  alors  que  les  resul- 
tats  pathologiques  des  generations  plus  ou  moins  attenuees,  en  rapport  avec  le  terrain 
d’ implantation,  c’est-ii-dire,  avec  les  differences  individuelles  des  organismes  dont  elle 
se  greffe.  Si  l’observation  de  la  maladie  nous  engage  aujourd’hui  it  soupc;onner  sa  nature 
microbienne,  quand  les  etudes  bacterioscopiques  nous  elargissent  journellement  le  c-er- 
cle  des  maladies  parasitaires,  c’est  encore  bien  remarquable,  it  l’appui  de  cette  theorie, 
que  les  medecins  des  temps  plus  recules,  des  temps  oil. on  ne  soup9onnait  quand  meme 
l’existence  de  ce  monde  invisible  et  pathogenique,  out  vante  dans  la  therapeutique  de 
la  diphtherie  des  agents,  qu’on  a dejit  reconnus  comme  de  puissants  antiseptiques. 

Le  monde  m6dical  quoiqu’il  le  fasse  encore  it  defaut,  la  preuve  experimentale,  la 
determination  du  microbe  specifique,  tire  ses  armes  contre  la  diphtherie  de  son  arsenal 
antiseptique,  c’est  qu’en  effet  on  ne  peut  s’opposer  aux  ravages  des  poisons  septiques 
que  par  des  agents  antiseptiques.  Une  fois  la  maladie  soupijonnee  microbienne;  pas  plus 
d’antiphlogistiques  des  evacuants  ni  meme  de  toniques  isolement  employes.  Son  trai- 
tement,  comme  celui  de  la  fi&vre  typho'ide,  celui  de  la  phthisie,  de  la  coqueluche  et 
d’autres  est  des  lors  franchement  antiseptique  et  si,  un  beau  jour,  comme  je  disais  tout 
it  l’heure,  il  nous  est  permis  de  deceler  le  microbe  diphtherique,  on  pratiquera  alors, 
peut-etre,  des  inoculations  du  virus  attenue,  comme  on  le  fait  presentement,  envers  la 
rage  (Pasteurs),  le  colera  (Ferranj,  la  fievre jaune  (Freire),  le  charbon  (Arloin),  etc. 

Dans  l’attente  d’un  charmant  avenir,  soyons  logiques  avec  l’observation,  et  recher- 
chons  un  agent,  qui  puisse  du  moins  rendre  l’economie  impropre  it  la  culture  de  ce 
microorganisme,  tout  en  restant  d’une  parfaite  innocuite  pour  l’organisme  humain. 

D’accord  avec  cette  maniere  d’envisager  la  question  j’ai  l’honneur  d’appeler  l’atten- 
tion  du  Congres  vers  un  traitement  de  la  diphtherie  qui  m’a  fourni  des  resultats  trfcs 
encourageants.  Je  n’oserais,  cependant,  vous  entretenir  it  la  lecture  d’une  statistique, 
superbe  d’ailleurs,  mais  dont  la  valeur  serait  nulle,  sans  l’observation  exacte  de  chaque 
cas.  Je  crois,  avec  Mr.  Forget : “Que  la  statistique  est  une  bonne  fille  qui  se  livre  au 
premier  venu.”  Je  vais  done  vous  faire  part  des  conclusions  auxquelles  je  suis  arrive 
et  je  vous  laisse  le  travail  du  controle. 

II  y a longtemps  que  je  constate  presque  journellement  la  haute  puissance  antisep- 
tique du  sulfure  de  calcium.  II  y a une  influence  favorable,  toujours  comme  medica- 
ment interne,  dans  certaines  otorrhees,  dans  la  tuberculose,  dans  la  diarrhee  reconnue 
infectieuse  et  envers  d’autre  affections  reputees  mirobiennes.  J’etais,  de  plus  en  plus 
encourage,  sur  son  action  antiseptique,  quand  je  me  suis  trouve  en  face  d’une  epidemie 
de  fievre  morbilleuse  qui  a ete  compliquee  de  diphtherie. 

On  devinera  aisemeut  que  j’avais  it  profiter  une  fois  de  plus  it  Faction  antivirulente 
du  sulfure,  je  devais  du  moins  l’employer,  d’accord  avec  mes  idees  sur  la  diphtherie. 
Je  n’ai  done  pas  hesit^  ii  l’administrer  dans  tous  les  cas,  et  mes  investigations  sur  son 
emploi,  m’ont  porte  aux  conclusions  suivantes  : — 

1°  Le  sulfure  de  calcium,  administre  it  l’iuterieur,  agit  par  l’hydrogene  sullur6 
qui  se  degage. 

2°  L’liydrogfene  sulfure  s’elimine  par  la  peau  et  par  les  muqueuses,  notamment  par 
la  muqueuse  respiratoire,  selon  qu’il  se  decide  par  les  r^actifs. 

3°  L’action  antiseptique  de  sulfure  m’a  imluit  it  l’administrer  dans  la  diphtherie 
dont  la  nature  microbienne  est  pour  moi  incontestable. 

4°  Sous  l’influence  de  sulfure  de  calcium  administre  de  bonne  heure,  la  diphtherie 
se  termine  favorablement,  l’engorgeineut  gauglionnaire  diminue,  la  lifevre  se  modere  et 


SECTION  XIII — LARYNGOLOGY. 


153 


les  fausses  membranes  diphtheriques  deviennent  plus  minces  et  moins  adherentes  sous 
l’action  excitante  que  l’hydrogkne  sulfure  produit  sur  les  muqueuses  qui  l’elimiuent. 
Cets  excitation  semble  les  rendre  improprete  it  la  reproduction  des  produits  morbides. 

5°  Le  sulfure  de  calcium  qu’on  peut  envisager  comme  l’agent  specifique  de  la 
diphtherie,  quand  on  l’administre  de  bonne  heure  ; est  impuissant  dans  les  cas,  oil  la 
diphtherie  est  tres  avancee,  et  dans  la  forme  infectieuse  aigue,  quand  les  fausses  mem- 
branes out  envahi  presque  toute  la  muqueuse  respiratoire.  Mais  ce  sont  des  cas  oil  on 
n’arrivera  jamais  it  la  gu6rison,  de  meme  qu’on  ne  peut  pas  gu£rir  une  phthisie  k sa 
troisiime  periode.  Tels  sont  alors  les  ravages  de  1’ infection  ! 

6°  Je  l’ai  administre,  en  outre,  i\  des  enfants  bien  portants  qui  se  trouvaient  dans 
un  foyer  d’infection  et  je  les  ai  vus  resister  it  la  contagion,  tant  que  d’autres  qui  n’a- 
vaient  pas  fait  usage  du  sulfure  ont  acquis  la  maladie.  Je  crois,  done,  pouvoir  l’attri- 
buer  une  action  prophylactique. 

7°  J’ai  administre  de  preference  les  granules  dosimetriques  du  Dr.  Burggraeve  de 
trois  a vingt,  et  meme  plus  par  jour,  selon  les  circonstances. 

8°  Les  excellents  resultats  obtenus  par  moi,  sont  dfis  exclusivement  au  sulfure  de 
calcium,  parce  qu’il  a ete  employe  isolement  pendant  la  periode  des  plus  grands  dan- 
gers de  la  diphtherie. 

9°  J’ai  eu,  nonobstant,  la  precaution  de  nettoyer  les  endroits  qu’on  pouvait  attein- 
dre,  avec  le  sue  de  citron,  moven  auquel  je  ne  crois  pas  qu’on  puisse  accorder  les  bene- 
fices dans  les  resultats  obtenus. 

Je  regrette  vivement  que  les  limites  restreintes  d’une  communication  m’empechent 
d’y  ajouter  les  reflexions,  auxquelles  je  suis  porte,  sur  l’action  d’un  agent,  qui  doit 
meriter  la  preference  dans  le  traitement  d’une  si  cruelle  maladie,  mais  en  vue  de  mtjna- 
ger  les  instants,  j’ai  l’honneur  de  laisser  & la  savante  consideration  de  mes  illustres 
collegues  le  contiole  des  conclusions  sur  lesquelles  j’ai  cru  devoir  entretenir  l’attention 
du  Congros  a qui  j’envoie,  d’ailleurs,  mes  plus  sinceres  et  respectueuses  salutations. 


Dr.  E.  Fletcher  Ingals,  of  Chicago,  moved  that  a vote  of  thanks  be  sent  to 
the  President,  Dr.  Daly,  on  behalf  of  this  Section,  for  his  endeavors  to  make  the 
meetings  of  this  Section  a success  and  also  to  Secretaries,  Drs.  W.  M.  Porter  and 
D.  N.  Rankin  for  the  valuable  aid  rendered. 


SECTION  XIV— DERMATOLOGY  AND  SYPHILOGRAPHY. 


OFFICERS. 

President:  PR.  A.  R.  ROBINSON,  New  York,  N.  Y. 


VICE-: 

Dr.  A.  H.  Ohmann-Dumesnil,  St.  Louis,  Mo. 
Prof.  Alfred  Fournier,  Paris,  France. 

Dr.  T.  Colcott  Fox,  London,  England. 

Prof.  A.  Hardy,  Paris,  France. 

Hans  Von  Hebra,  Vienna,  Austria. 

1 J.  Hutchinson,  f.  r.  s.,  London,  England. 

; Dr.  W.  Allan  Jamieson,  Edinburgh,  Scotland, 
Prof.  Moriz  Kaposi,  Vienna,  Austria. 

Dr.  P.  G. 


PRESIDENTS. 

Dr.  James  M.  Keller,  Hot  Springs,  Ark. 
Prof.  Oscar  Lassar,  Berlin,  Germany. 
Prof.  H.  Leloir,  Lille,  France. 

Prof.  Isidor  Neuman,  Vienna,  Austria. 

Dr.  August  Ravogli,  Cincinnati,  Ohio. 
Prof.  Schwimmer,  Buda-Pesth,  Hungary. 
Dr.  John  V.  Shoemaker,  Philadelphia,  Pa 
Dr.  George  Thin,  London,  England. 
Unna,  Hamburg. 


SECRETARY. 

Dr.  Wm.  S.  Gottheil,  N.  Y, 


Dr.  Wm.  T.  Belfield,  Chicago,  III. 

Dr.  John  D.  Duncan,  Kansas  City,  Kan. 
Dr.  W.  F.  Glenn,  Nashville,  Tenn. 


COUNCIL. 

Dr.  Chas.  C.  Jemans,  Detroit,  Mich. 
Dr.  Edw.  R.  Palmer,  Louisville,  Ky. 
Dr.  Chas.  G.  Smith,  Chicago,  111. 


155 


156 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


FIRST  DAY. 

4 


ADDRESS. 

BY  A.  R.  ROBINSON,  M.  B.,  L.  R.  C.  P.  & S., 

President  of  the  Section. 

It  devolves  upon  me  as  chairman  of  the  Section  of  Dermatology  and  Syphilo. 
graphy  to  perform  the  very  pleasant  duty  of  offering,  on  behalf  of  my  American 
colleagues,  a most  hearty  welcome  to  our  foreign  co-workers  who  honor  us  with  their 
presence,  and  give  us  such  fresh  proofs  of  their  deep  interest  in  science  by  traveling 
so  far  to  attend  this  meeting  and  to  take  an  active  and  important  part  in  the  pro- 
ceedings, although  from  our  past  history  they  must  have  very  slight  hope  of  any 
intellectual  compensation  from  us.  And  whilst  we  do  not  promise  them  as  warm  a 
reception  from  the  authorities  who  regulate  our  weather  conditions,  as,  according  to 
rumor,  the  wind  organs  from  certain  quarters  promised  them  weeks  and  months  ago; 
yet  they  may  rest  assured  that  we  are  very  glad  indeed  to  see  them  present,  and 
whilst  we  recognize  them  as  leaders,  as  representative  men  in  our  special  department, 
the  men  who  have  done  and  are  still  doing  real  scientific  work,  and  in  whom  we  place 
much  hope  for  future  advancement  of  our  knowledge  of  subjects,  still  altogether  too 
numerous  in  this  branch  of  medicine,  of  which  we  know  almost  nothing  ; we  would 
also  gladly  have  welcomed  a greater  number  of  their  colleagues,  and  regret  the 
absence  of  several,  who,  from  illness  or  other  causes,  are  unable  to  be  present, 
although  most  anxious  to  have  come. 

It  is  fortunate  that  the  heat  will  not  be  so  great  as  the  false  prophets  promised, 
for,  knowing  the  effects  of  high  temperature  upon  the  mental  powers,  and  the 
amount  of  raiment  one  can  wear  under  great  heat  conditions  ; and  that  these  medical 
congress  meetings  are  partly  scientific  and  partly  social  in  their  character,  it  is  evident 
that  for  a successful  congress  of  this  kind,  the  participants  must  be  clothed,  and  in 
their  right  minds.  If  the  social  part  is  a comparative  failure,  I trust  that  the  mental 
food  offered  will  be  rich  in  valuable  material.  The  American  supply  to  past  congress 
meetings  has  been  an  unknown  quantity;  for  this  meeting  we  already  know  the  quan- 
tity, and  will  soon  know  the  quality. 

You,  as  specialists,  are  too  familiar  with  the  dermatological  literature  of  America, 
vast  in  yearly  amount,  meagre  in  contributions,  not  to  wonder  why,  with  so  many 
writers  upon  the  subject,  with  so  many  dermatologists  animated  with  that  peculiar 
American  quality  called  “ push,”  we  have  contributed  so  little  to  the  recent  substan- 
tial advancement  in  our  knowledge  of  skin  diseases.  But  if  we  cousider,  as  we  now 
intend  to  do  briefly,  all  the  conditions  under  which  we  pursue  our  studies  iu  this 
country,  it  will  appear  strange  that  good  work  is  not  even  rarer  than  it  now  is. 

Taught  in  colleges  the  majority  of  which  require  only  a two  years  course  of  study, 
the  sessions  of  each  year  lasting  five  or  six  months,  what  inducement  do  such  colleges 
hold  out  to  their  students  to  study  medicine  as  it  should  be  studied,  if  they  are  to  be 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGRAPHY. 


157 


ther  than  the  blindest  followers,  in  the  pursuit  of  our  profession,  of  the  advice 
; iceived  from  a few  lectures  or  compendiums.  Such  a college  course  was,  perhaps, 
ot  objectionable  in  colonial  days,  or  when  physicians  were  not  a drug  upon  the  pub- 
c,  as  they  may  be  said  to  be  now,  when  every  village  is  overcrowded,  and  continual 
fforts  to  get  patients  are  necessary  to  enable  the  professional  man  to  build  up  a 
ractice,  and  at  the  same  time,  financially,  to  make  both  ends  meet.  It  must  be 
lear  to  the  members  of  every  teaching  faculty  in  the  land  that  a two,  or  even  a three 
ears  course  of  study  is  quite  inadequate  to  prepare  a student — even  if  he  be  a 
tudeut  in  the  best  sense  of  the  term,  bright  and  diligent— for  the  responsible  duties 
f a medical  practitioner;  for  the  faculty  is  the  examining  body,  and  the  superficial 
nowledge  of  candidates  for  graduation  must  be  painfully  evident  to  the  professors. 

Lectures  upon  special  subjects  are  given  in  the  majority  of  the  colleges,  and  in 
ome  of  them  dermatology  is  considered  as  a special  subject,  in  which  case  one  clinical 
i icture  a week  is  usually  given.  As,  however,  no  examination  upon  the  subject  is 
equired  for  graduation,  the  majority  of  students  absent  themselves  from  the  lectures, 
■ut  afterward  receive  their  diploma,  certifying  to  their  knowledge  of  medicine  in  all 
ts  branches;  although  they  may  not  have  seen  a single  case  of  cutaneous  disease,  and 
1 ould  not  diagnose  au  ordinary  syphilide  from  an  eczema  ; or  even  an  elephantiasis 
fom  a scleroderma. 

Afterward,  in  practice,  however,  they  treat  all  patients  with  cutaneous  disease 
without  hesitation,  as  a rule,  and  with  the  utmost  coolness  and  outward  appearance 
.f  confidence  in  their  knowledge  of  the  ‘ ‘ rash,  ’ ’ for  to  them  it  is  rash  and  nothing 
nore.  I am  not  blaming  those  general  practitioners  who  follow  this  course  ; it  is  the 
legitimate  result  of  the  doctrine  of  the  teaching  body,  for  with  only  a two  or  three 
rears  course  it  is  not  possible  to  devote  time  to  subjects  upon  which  they  are  not  to 
; >e  examined.  Neither  do  these  remarks  apply  to  those  general  practitioners,  of  whom 
here  is  quite  a number,  who  have  devoted  post-graduate  time  to  the  study  of  cuta- 
neous diseases. 

But  a yearning  after  practical  points — what  drag  to  give  for  this  or  that  disease ; 
vhat  is  the  best  prescription  for  an  eczema  for  instance — signs  pathognomonic  of 
mperfect  mental  training,  and  the  lack  of  clinical  experience,  and  of  the  information 
nntained  in  good  text-books  upon  special  subjects,  bring  about  other  evils  which 
; )articularly  concern  us  as  dermatologists,  and  to  which  I will  directly  refer. 

On  account  of  the  few  lectures  given  upon  skin  diseases  and  the  short  course 
if  study  required,  it  is  not  possible  to  learn  dermatology  in  this  country,  except  under 
i rreat  disadvantages  at  least.  It  is  true  that  private  instruction  can  be  obtained  at 
iome  dispensaries,  and  that  regular  clinics  are  held  at  some  of  the  post-graduate 
' ichools;  but  for  any  extended  knowledge  of  the  subject  a trip  to  Europe  has  hitherto 
jeen  considered  necessary.  Vienna  has  usually  been  the  Mecca  for  those  who  wish 
,o  specially  study  this  subject,  as  the  magnificent  material  to  be  seen  at  the  Hopital 
! 5t.  Louis  has  not  drawn  many  students  to  Paris,  while  in  London  the  patients  are 
lot  used  specially  for  teaching  purposes,  and  consequently  the  advantages  for  studying 
he  subject  are  not  to  be  compared  to  those  of  Vienna. 

How  long  the  student,  now  a physician,  remains  abroad  depends  usually  upon  his 
deas  of  the  proper  course  to  pursue,  and  the  amount  of  money  at  his  command. 
He  should  remain  several  years  for  the  study  of  histology,  pathology,  morbid  anat- 
1 liny,  internal  medicine,  bacteriology,  and  skin  diseases,  if  he  intends  practicing  after- 
ward as  a specialist;  but  that  is  not  the  course  usually  pursued.  He  devotes  too 
much  time  to  learning  the  diagnosis  and  treatment  of  skin  diseases,  a course  very 
proper  for  a general  practitioner,  but  not  for  one  who  ever  hopes  to  advance  our  pres- 


158 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ent  knowledge  of  cutaneous  diseases;  for  who  can  expect  to  add  to  the  descriptions 
of  clinical  symptoms  as  given  by  such  acute  observers  as  Hebra,  Wilson,  Tilbury  Fox, 
etc. , observers  who  have  devoted  their  lives  to  the  subject  and  seen  their  thousands 
and  tens  of  thousands  of  cases.  I do  not  say  that  it  is  impossible  to  do  so,  but  he 
has  not  a heavy  heart  or  weak  imagination  who  expects  to  make  a reputation  in  that 
direction.  To  combine,  as  is  frequently  done,  the  subject  of  cutaneous  with  genito- 
urinary diseases,  instead  of  with  internal  medicine,  is  a serious  error;  for  the  two 
classes  of  diseases  are  in  no  way  related  to  each  other,  and  a knowledge  of  the  one 
does  not  aid  us  in  the  study  of  the  other;  while  eveiy  one  must  admit  the  close  setio- 
logical  relationship  of  many  cutaneous  diseases  with  internal  pathological  conditions. 

Histology,  normal  and  pathological,  bacteriology,  and  general  pathology  hold  the 
same  relations  to  dermatology  that  they  do  to  the  other  branches  of  medicine  and  sur- 
gery; that  is,  they  are  essential  to  the  foundation  of  a broad  view  of  the  subject,  and 
no  one  can  fully  discuss  the  aetiology  of  the  majority  of  diseases — that  important 
branch  of  medical  science  which  at  the  present  time  is  studied  more  than  any  other — 
without  some  knowledge  of  them. 

Whether  the  student  remains  abroad  for  a few  months  only,  or  several  years,  he 
receives  the  foundation  of  his  dermatological  knowledge  in  foreign  lands,  be  that 
slight  and  dangerous,  or  broad  and  capable  of  being  built  upon,  according  to  the  time 
and  brain  energy  spent.  The  majority  of  dermatologists  at  present  practicing  in 
America  have  obtained  their  schooling  in  dermatology  in  other  countries,  and  as  they 
continue  afterward  to  be  more  or  less  influenced  by  the  teaching  received  abroad,  they 
may  be  called  followers  of  this  or  that  school,  depending  upon  the  country  in  which 
they  studied. 

A school  can  exist  only  when  there  is  a comparatively  great  dermatologist  in  a 
given  country,  one  whose  views  are  more  or  less  unreservedly  accepted,  and  his  teach- 
ings followed  by  his  countrymen  and  pupils,  or  when  the  leading  dermatologists  of  a 
country  hold  similar  and  peculiar  views.  As  our  knowledge  of  cutaneous  diseases 
increases,  and  the  number  of  dermatologists  multiplies,  there  is  more  and  more  diffi- 
culty in  founding  a school,  so  that  at  the  present  time  we  are  scarcely  justified  in 
speaking  of  a Herman,  French  or  English  school,  for  in  all  these  countries,  eminent 
dermatologists,  of  whom  there  are  always  several  in  each  country,  hold  very  widely 
different  views  concerning  the  aetiology,  nature  and  treatment  of  the  inflammatory 
affections  of  the  skin,  and  it  is  upon  the  divergence  of  views  in  reference  to  this  class 
of  diseases  particularly,  that  schools  have  existed. 

As  there  is  no  particular  centre  for  dermatological  study  in  America,  as  there  is 
no  comparatively  great  dermatologist,  and,  finally,  as  the  majority  of  dermatologists 
have  had  their  schooling  abroad,  and  hold  widely  different  views  on  the  inflammatory 
and  the  other  cutaneous  diseases,  there  is  no  such  a thing  as  an  American  school  ot 
dermatology;  consequently  also  there  cannot  be  a representative  American  dermatol- 
ogist, for  there  are  no  special  American  views  of  dermatology  to  be  represented. 

This  is  specially  gratifying  to  your  chairman,  for,  that  being  true,  it  logically 
follows  that  it  cannot  be  said  of  him  for  the  present  occasion  that  he  is  not  a good 
representative  of  American  dermatology.  As  independent  workers  each  of  us  repre- 
sents but  the  character  of  our  own  labors,  and  if  that  is  not  creditable,  the  author  is 
a corresponding  dermatologist.  If  the  work  done  by  American  dermatologists,  as  a 
whole,  is  to  be  represented,  then  the  position  should  not  be  a difficult  one  to  fill,  l°r 
the  average  of  that  work  is  not  astonishingly  high,  as  shown  by  the  articles  in  jour- 
nals, and  the  reports  of  our  special  societies. 

Returning  from  his  European  travels — “speaking  a foreign  language  just  as  well 


r 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY.  159 

as  his  mother  tongue  ” — the  would-be  specialist  is  beset  by  temptations,  to  which  he 
too  frequently  falls  a victim.  With  more  medical  journals  in  the  land  than  are  ne- 
ii  cessary  for  the  publication  of  papers  that  repay  one  for  their  perusal,  there  is,  on  the 
one  hand  a demand  for  an  article  on  some  subject — it  matters  not  what  it  be — by 
the  editor;  and  on  the  other  hand,  a desire  to  publish  a paper  by  the  specialist  anx- 
ious for  reputation  and  notoriety.  The  medical  world  at  least  must  know  that  he  is 
devoting  special  attention  to  a particular  branch  of  medical  science,  and  what  plan  so 
good  as  to  write  an  article  for  a journal,  and,  by  means  of  reprints  scattered  broadcast 
let  the  world  know  your  specialty,  name  and  address.  A few  repetitions  of  this  pro- 
cedure will,  without  fail,  bring  patients  to  the  office,  and  reputation  among  the  mass 
of  general  practitioners.  Why  this  latter  is  a result  is  not  difficult  to  understand. 
As  already  mentioned,  the  college  graduates  usually  have  no  knowledge  of  the  so- 
called  special  branches,  consequently  any  reprint,  although  it  be  only  a compilation  of 
previous  articles  by  real  workers — and  very  often  they  are  even  very  poor  compila- 
tions— appears  to  the  busy  practitioner  to  contain  valuable  information,  and  the 
author  thereof  as  one  having  special  knowledge  of  his  subject. 

This  mode  of  action  is  a very  serious  evil,  and  must  and  does  bring  discredit  upon 
the  specialists  in  that  branch,  as  a body.  It  is  to  be  hoped  that  the  protest  I now 
enter  against  this  evil  will  not  be  in  vain,  and  that  in  the  future  only  such  articles 
will  be  published  as  represent  real  contributions  to  the  existing  knowledge  of  the  sub- 
h ject  discussed.  We  still  have  so  little  real  knowledge  of  diseases  of  the  skin  that  there 
is  a wide  field  for  future  observation,  and  the  energy  wasted  in  the  compilation  of 
these  papers  should  be  devoted  to  original  and  more  creditable  work.  Let  us  show 
that  American  dermatologists  have  the  spirit  and  ability  to  do  their  share  of  work  for 
the  advancement  of  our  knowledge  in  their  special  branch  of  medical  science.  I do 
not  wish  to  be  considered  as  maintaining  in  this  address  that  no  good  work  has  ever 
been  done  in  this  country,  for  that  would  not  be  correct;  but  it  has  borne  no  proper 
proportion  to  the  number  of  articles  which  have  been  published,  for  too  often  the 
heading  of  a paper  as  a “ contribution  ’ ’ to  our  existing  knowledge  of  this  or  that 
j disease  has  scarcely  been  justified  by  the  contents. 

As  we  learn  most  from  a contemplation  of  our  errors,  I have  endeavored  to  draw 
attention,  as  regards  dermatology  in  America,  to  the  faults  of  the  colleges  with  refer- 
ence to  this  branch  and  the  errors  of  action  which  we  as  specialists  are  liable  to  com- 
mit for  our  personal  advancement,  and  have  pointed  out  the  way  by  which  creditable 
reputation,  if  not  pecuniary  success,  can  always  be  attained. 

Finally,  in  view  of  past  events,  I desire  to  express  the  hope  that  another  Inter- 
national Medical  Congress  will  not  be  held  in  America  until  the  profession  in  this 
J country  have  shown  by  their  actions  a change  of  heart  ; that  they  are  prepared  to 
subject  the  desire  for  personal  gain  to  the  proper,  nobler  and  more  honorable  feeling 
for  the  advancement  of  medical  science  and  consequent  relief  of  human  suffering. 


160 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


VACCINATION  DURING  THE  INCUBATION  PERIOD  OF  VARIOLA. 

LA  VACCINATION  PENDANT  LA  PERIODE  D’lNCUBATION  DE  LA  VARIOLE 

(PETITE  VERSlE). 

UBER  IMPFUNG  W AHREND  DER  INKUBATIONSPERIODE  DER  BLATTERN. 

BY  WM.  M.  WELCH,  M.  I). , 

Of  Philadelphia,  Pa. 

It  is  not  an  irrational  supposition  that  the  infecting  principle  of  a contagious  disease 
does  not  lie  dormant  in  the  system  during  the  interval  between  its  reception  and  the 
earlier  manifestations  of  the  disease,  but  rather  that  certain  unknown  processes  go  on 
during  this  period,  although  no  distinct  symptoms  indicating  such  action  are  yet 
apparent.  The  question  as  to  whether  it  is  possible  in  any  case  to  arrest  or  so  change 
these  processes  as  to  prevent  or  modify  the  approaching  disease,  is  one  about  which 
there  is  a difference  of  opinion.  Pasteur  claims  that  he  is  able  to  prevent  hydrophobia 
by  inoculation  during  the  incubation  period  of  that  disease,  and  I shall  endeavor  to 
show,  without  any  claim  for  originality,  that  vaccination  during  the  corresponding  period 
of  smallpox  lias,  in  my  hands,  given  well-marked  and  encouraging  results. 

An  ingenious  effort  has  been  made  recently,  by  an  able  writer,  to  prove,  by  a process 
of  reasoning  alone,  that  when  the  microorganisms  of  smallpox  have  once  gained  access 
to  the  circulation,  the  introduction  of  the  microorganisms  of  vaccinia — both  microbes 
being  essentially  the  same — can  have  no  other  effect  than  to  quicken  the  action  of  the 
former.  The  conclusion  is  that  vaccination  during  this  period  is  worse  than  useless, 
since  it  serves  both  to  precipitate  and  intensify  the  incubating  disease.  I refer  to  this 
theory  only  to  say  that  it  is  unsupported  by  facts,  and  utterly  untenable. 

In  regard  to  the  power  of  vaccination  during  the  period  of  incubation  of  smallpox, 
the  opinion,  and  I may  say  also,  the  experience  of  writers  seem  to  differ.  Curschmann, 
the  author  of  the  article  on  smallpox  and  vaccination  in  Ziemssen’s  Cyclopaedia  of  the 
Practice  of  Medicine,  writes:  “Are  we  able  to  exert  any  influence  on  the  disease  in  the 
early  stage  preceding  the  eruption?  Is  it  possible  in  infected  persons  during  the  stages 
of  incubation  and  invasion  to  cut  short  the  disease  or  to  modify  its  course?  Many 
attempts  have  been  made  to  answer  these  questions  affirmatively,  but  as  yet  without 
much  result.  The  first  idea  was  vaccination,  and  this  was  employed  by  some  in  the 
ordinary  way . . . . “ but  that  ordinary  vaccination  during  the  stages  of  inva- 

sion and  incubation  cannot  stay  the  disease,  has  been  proved  to  me  by  chance  observa- 
tions and  direct  experiments.  On  the  contrary,  I have  seen,  in  cases  in  which  vaccina- 
tion was  practiced  after  infection  with  variola,  vaccine  pustules  and  smallpox  pustules 
developed  side  by  side.  It  is,  in  my  opinion,  very  doubtful  whether  vaccination  can 
even  render  the  course  of  the  disease  milder.” 

I quite  agree  with  Curschmann  that  vaccination  during  the  initial  or  invasive  stage 
of  smallpox  is  valueless  ; and  if  it  be  done  only  a very  few  days  prior  to  this  stage  it  is 
equally  valueless.  But  I am  prepared  to  say  if  it  be  performed  very  early  in  the  incu- 
bative stage  it  will  frequently  modify  the  attack,  and  sometimes,  indeed,  prevent  it 
absolutely.  To  be  more  explicit : vaccination  performed  less  than  seven  days  prior  to 
the  appearance  of  the  variolous  eruption  exerts,  as  a rule,  no  modifying  influence  what- 
ever ; the  vaccine  vesicles  and  the  variolous  pustules  develop  side  by  side,  without 
either  of  them  being  materially  changed  in  their  course.  It  is  my  opinion  that  vaccinia 
does  not  begin  to  exert  its  prophylactic  power  until  the  vesicle  has  reached  the  stage  of 
formation  of  the  areola.  If  this  stage  be  reached  before  sickening  for  smallpox  occurs, 
the  disease  may  be  entirely  prevented  ; if  not  until  after  sickening,  but  before  the  erup- 
tion appears,  it  may  modify  the  attack.  Knowing  the  length  of  the  period  of  incuba- 
tion of  smallpox  to  be,  in  the  majority  of  cases,  ten  or  eleven  days  until  the  initial 
symptoms  occur,  or  twelve  or  thirteen  days  until  the  eruption  appears,  it  is  evident  that 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


161 


in  order  to  confer  protection,  either  complete  or  partial,  vaccination  must  not  be  very- 
long  delayed  after  the  contagium  has  been  received  into  the  system.  Of  course,  it 
should  be  performed  immediately  after  exposure,  but  if  through  inadvertency  or  impos- 
sibility this  is  not  done,  and  a number  of  days  have  been  allowed  to  pass  since  infection 
occurred,  it  still  should  be  performed,  for  the  period  of  incubation  of  smallpox  is  not 
invariable  as  to  time ; it  is  sometimes,  for  some  reason,  prolonged,  in  which  case  a later 
vaccination  may  prove  of  value. 

Although  the  presence  of  the  areola  generally  determines  the  period  of  the  vaccine 
disease  at  which  protection  is  brought  about,  yet  there  seems  sometimes  to  be  in  dividual 
differences  in  regard  to  this  period.  I have  seen  persons  exposed  to  the  contagion  of 
smallpox  at  the  same  time  and  in  such  a manner  that  there  could  be  no  doubt  about 
infection  taking  place;  have  vaccinated  such  persons  at  the  same  time  and  with  the 
same  virus,  and  the  vaccine  disease,  to  all  appearances,  has  pursued  courses  identical, 
yet  one  enjoyed  perfect  protection  and  the  other  only  partial,  or,  in  other  similar  in- 
stances, one  has  received  partial  protection  and  the  other  none  at  all.  This  difference 
is  doubtless  due  to  some  individual  peculiarity  that  cannot  be  explained. 

It  is  much  easier  to  confer  protection  after  exposure  to  the  contagion,  when  re-vac- 
cination  is  required,  than  when  the  vaccination  is  primary.  The  reason  of  this  is  very 
plain : it  is  because  the  modified  form  of  vaccinia  induced  by  re- vaccination  develops 
more  speedily  and  completes  its  entire  course  in  a much  shorter  time;  hence  prophylaxis 
is  established  at  an  earlier  period.  Of  course,  the  nearer  this  modified  form  of  vesicle 
approaches  to  the  true  standard,  the  longer  is  the  point  of  protection  in  being  reached. 

The  character  of  the  vaccine  vesicle  has  much  to  do  in  the  matter  of  establishing 
speedy  protection.  One  that  is  prompt  and  typical  in  its  manifestations  is  most  to  be 
desired.  A tardy  vesicle — slow  in  making  its  appearance  and  late  in  arriving  at 
maturity — always  increases  my  anxiety  for  the  safety  of  an  individual  in  whom  small- 
pox is  incubating.  It  is  not  uncommon  nowadays  to  see  vesicles  two,  three  or  more 
days  late  in  making  their  appearance,  and  correspondingly  slow  in  running  their  course. 
Of  course  such  a vaccination  at  this  stage  of  variola  could  scarcely  be  expected  to 
modify  the  disease,  much  less  to  prevent  it. 

Quality  of  vaccine  virus  has  almost  everything  to  do  in  the  matter  of  determining 
the  character  of  the  vesicle.  Animal  lymph  is  too  unreliable,  and,  when  it  does  suc- 
ceed, too  slow  in  its  action  to  he  trusted  at  this  period  of  smallpox.  Failure  or  success 
with  vaccination  at  this  time  might  make  the  difference  between  life  and  death.  There- 
fore virus  which  is  reliable  and  quick  should  be  preferred.  I know  of  none  that  is 
better  than  fresh  eight-day  lymph,  taken  directly  from  a typical  vaccine  vesicle  ; but 
as  opportunity  for  obtaining  such  virus  seldom  occurs  at  the  propitious  moment,  I am 
in  the  habit  of  using  humanized  virus  in  the  form  of  crust,  preferring  that  which  has 
had  a long  succession  of  human  transmissions. 

There  is  no  question  but  that  vaccine  virus  of  very  long  humanization  induces  a 
type  of  vaccinia  of  much  shorter  duration  than  that  induced  by  animal  lymph  or  by 
virus  of  recent  humanization.  Prior  to  the  introduction  of  animal  vaccination  in  this 
country,  in  1870,  by  the  late  Dr.  Henry  A.  Martin,  the  virus  in  general  use  here  was 
doubtless  of  the  same  stock  as  that  which  was  then  in  use  at  the  National  Vaccine 
Institution  of  Great  Britain;  for  in  either  case  the  type  of  vaccinia  induced  had  a dura- 
tion of  only  fourteen  or  fifteen  days,  counting  from  the  insertion  of  the  virus  until  the 
falling  off  of  the  crust.  A vaccine  disease  of  this  description  is  attended  by  a more 
speedy  development  of  the  vesicle,  and  an  earlier  appearance  of  the  areola,  than  is  the 
case  in  the  more  typical  form  of  the  disease,  and  consequently  it  can  be  used  with 
greater  effect  against  incubating  smallpox. 

I do  not  wish  to  be  understood  as  preferring  for  general  use  the  virus  just  described. 
When  time  is  not  so  great  an  object,  animal  lymph  or  lymph  of  comparatively  recent 
humanization  is  greatly  to  be  preferred,  because  it  gives  rise  to  a vaccine  disease  corre- 
Vol.  IV— 11 


162 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


sponding  very  exactly  to  Jenner’s  description  of  true  vaccinia,  and  confers  protection 
not  only  for  the  time  being,  but  of  the  greatest  possible  durability.  That  long-human- 
ized virus  is  capable  of  exerting  a prophylactic  power  against  smallpox  for  a time,  at 
least,  I am  quite  sure;  for  in  my  efforts  to  confer  protection  after  variolous  infection  has 
occurred  it  has  given  me  my  best  results.  I am,  however,  firmly  of  the  opinion  that 
the  prophylactic  power  exerted  by  this  virus  is  not  as  durable  as  that  exerted  by  virus 
which  induces  the  most  typical  form  of  vaccine  disease.  Therefore,  I say  where  time 
is  not  an  object,  animal  lymph  or  lymph  of  recent  humanization  should  be  preferred. 

There  is  yet  one  point  of  considerable  importance  to  which  I desire  to  call  attention, 
and  that  is,  iu  the  use  of  long-humanized  virus  it  is  advisable  that  each  vaccination  be 
made  up  by  a number  of  insertions.  By  this  means  we  not  only  increase  the  chances 
of  establishing  the  vaccine  disease,  but  aid  in  bringing  the  system  more  decidedly  and 
effectually  under  its  influence.  Furthermore,  it  has  been  claimed  by  competent  obser- 
vers that  multiple  insertions  serve  to  expedite  the  processes  of  vaccinia,  and  thus  hasten 
the  attainment  of  that  point  in  the  disease  at  which  prophylaxis  is  exerted. 

As  long  ago  as  the  year  1808,  Dr.  Benjamin  Waterhouse,  who,  on  account  of  the 
commendable  enthusiasm  he  displayed  in  the  matter  of  the  introduction  of  vaccination 
in  this  country,  received  from  his  British  friends  the  appellation  of  “ The  Jenner  of 
America,”  wrote  as  follows:  “I  think  it  proper  to  publish  an  important  fact  for  which 
we  are  not  indebted  to  Europe,  namely,  If  a person  be  inoculated  with  the  kine-poclc  two 
days  after  having  received  the  casual  infection  of  smallpox,  the  kine-pock  will  predominate 
and  save  the  patient.  Nay,  I will  go  further  and  say  in  some  cases  three  days  posterior  to 
infection  instead  of  two;  for  there  is  a mode  of  expediting  the  operation  of  the  kine- 
pock  virus  by  increasing  the  quantity  of  matter  thrust  under  the  epidermis;  and  it 
appears,  from  experiment,  that  this  does  not  depend  so  much  on  increasing  the  quantity 
put  into  a deep  puncture,  as  it  does  on  the  increase  of  infected  surface.  In  other  words, 
you  may  expedite  the  processes  of  kine-pock  inoculation  two  days,  if  not  three,  if, 
instead  of  two  punctures,  you  make  sixteen  or  twenty,”  . . . “and  on  the  sixth  day 
from  the  operation  we  shall  have  the  appearance  of  the  eighth  day  iu  ordinary  cases; 
and  on  the  eighth  day  we  shall  fin,d  the  appearance  of  the  tenth,  and  so  on  with  the 
febrile  symptoms,  in  which  commotion  the  prophylactic  power  consists.” 

I am  hardly  prepared  to  say  from  my  own  observation  that  it  is  possible  to  quicken 
the  course  of  vaccinia  to  the  extent  mentioned  by  Waterhouse,  but  that  the  processes 
of  the  disease  may  be  somewhat  hastened  by  multiple  insertious,  I have  no  doubt.  In 
looking  back  over  my  experience  I have  to  regret  that  my  vaccinations  after  infection 
had  occurred  were,  in  so  many  instances,  limited  to  a single  insertion. 

The  extent  of  my  experience  in  the  matter  of  vaccination  during  the  incubation 
period  of  smallpox  amounts  to  144  observations.  As  the  time  at  my  disposal  will  not 
permit  of  a detailed  account  of  each  case,  I can  only  present  in  tabular  form,  appended 
hereto,  some  of  the  more  important  facts  in  their  clinical  histories.  I wish  to  empha- 
size the  fact  that  the  vaccinations  in  every  case  were  primary,  and  that  infection  most 
assuredly  had  taken  place  prior  to  their  performance. 

An  analysis  of  the  144  cases  referred  to  shows  as  follows:  In  twenty-eight  instances 
protection  against  smallpox  was  perfect;  in  eleven,  almost  perfect;  in  nineteen,  well 
marked;  in  twenty  it  was  partial,  and  in  sixty -six  there  was  none  at  all. 

In  fifty-four  instances  vaccination  had  been  performed  no  longer  than  from  two  to 
seven  days  before  the  variolous  eruption  appeared;  of  these  forty-two  per  cent.  died. 
While  in  ninety  instances  it  was  performed  at  an  earlier  period  in  the  stage  of  incuba- 
tion, and  of  these  only  fifteen  per  cent.  died.  The  death-rate,  doubtless,  would  have 
been  less  had  not  the  vaccine  vesicles  in  so  many  cases  been  so  tardy  in  their  develop- 
ment. When  I tell  you  that  the  death-rate  among  the  unvaccinated  cases  under  treat- 
ment at  the  same  time  and  place  amounted  to  fifty-nine  per  cent.,  the  value  of  vaccina- 
tion during  the  incubation  period  of  variola  surely  becomes  very  apparent. 


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41 

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Varioloid 

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7 

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Home 

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8 

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45 

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7 

10  yrs. 

Variola 

Home 

Before 

Tardy 

9 

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3 

8 

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No  disease 

Variola 

Home 

Before 

Regular 

6 

None 

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2 

9 

23  yrs 

Variola 

Home 

Before 

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8 

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19 

10 

6 mos. 

No  disease 

Home 

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7 

11 

18  yrs. 

Varioloid 

Home 

Before 

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11 

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marked 

... 

14 

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12 

12  yrs. 

Variola 

Home 

Before 

Regular 

3 

None 

39 

13 

14  yrs. 

Variola 

Home 

Before 

Regular 

3 

None 

Died 

7 

14 

19  yrs. 

Varioloid 

Home 

Before 

Regular 

9 

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marked 

13 

15 

10  yrs. 

Variola 

Home 

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6 

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35 

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20 

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ly, and  repeated 
every  day  for  five 
days  in  succession. 
Only  one  vesicle 
matured. 

17 

31  yrs. 

Variola 

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Before 

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8 

None 

30 

18 

5 yrs. 

Variola 

Home 

Before 

Regular 

5 

None 

21 

The  vaccine  vesicle 

19 

16  yrs. 

Variola 

Home 

Before 

Very 

tardy 

9 

None 

Died 

12 

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late  in  its  develop- 

ment. 

20 

18  yrs. 

Variola 

Home 

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Regular 

4 

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3 

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admission.  Moth- 
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21 

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Home 

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2 

Regular 

Perfect 

26 

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time,  only  the  lat- 
ter take. 

22 

10  mos. 

Varioloid 

Home 

Before 

Regular 

7 

Partial 

34 

23 

3 yrs. 

Varioloid 

Home 

Before 

Regular 

9 

Partial 

33 

24 

13  yrs. 

Variola 

Home 

Before 

Fair  but 
tardy 
Regular 

7 

None 

41 

25 

5 yrs 

Varioloid 

Home 

Before 

10 

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30 

26 

7 mos. 

Variola 

... 

Home 

Before 

Regular 

3 

None 

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6 

27 

17  yrs. 

Variola 

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3 

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35 

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28 

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The  eruption  con- 
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Varioloid 

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to  tak  e care  of 
child  sick  with 
that  disease.  Vac- 
cinated on  day  of 
birth,  and  also  on 
the  following  day. 

32 

3 yrs. 

Variola 

Home 

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4 

None 

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2 

The  variolous  erup- 

33 

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No  disease 

Varioloid 

Home 

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7 

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17 

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only  3 or  4 small 
vesicles. 

34 

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10 

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21 

35 

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... 

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7 

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36 

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Home 

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14 

37 

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28 

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virus  used  seemed 
to  be  particularly 
slow  in  its  action. 

39 

1 yr. 

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... 

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After 

2 

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Perfect 

20 

40 

2 yrs. 

No  disease 

... 

Home 

After 

2 

Regular 

Perfect 

19 

41 

3 vrs. 

No  disease 

Varioloid 

Home 

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2 

Regular 

5 

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30 

Disease  apparently 
modified. 

42 

18  yrs. 

Varioloid 

... 

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li 

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... 

35 

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43 

16  yrs. 

Variola 

Home 

Before 

Regular 

5 

None 

31 

44 

7 yrs. 

Variola 

Home 

Before 

Regular 

11 

None 

Pied 

7 

45 

5 yrs. 

Variola 

... 

Home 

Before 

Regular 

9 

None 

Died 

6 

46  2 to  yrs. 

Variola 

... 

Home 

Before 

Regular 

10 

None 

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c 

47 

6 mos. 

Variola 

... 

Home 

Before 

Tardy 

9 

None 

Died 

7 

48 

20  mos. 

No  disease 

Variola 

Home 

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Regular 

4 

None 

... 

27 

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sis  ted  ofonly  about 

49 

3 mos. 

Nodisease 

Varioloid 

Home 

After 

3 

Regular 

11 

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perfect 

27 

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vesicles.  The  gen- 
eral health  of  the 
child  was  hut  little 

if  at  all  disturbed. 

50 

17  yrs. 

Variola 

... 

Home 

Before 

Regular 

9 

None 

27 

51 

9 yrs. 

No  disease 

Home 

Before 

2 

Regular 

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... 

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52 

24  yrs. 

Measles 

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53 

36  yra. 

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Hospital 

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Typical 

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... 

29 

Sent  to  hospital  as 
smallpox. 

Sent  to  hospital  as 

11 

smallpox ; vacci- 

54 

18  yrs. 

Roseola 

Varioloid 

Hospital 

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3 

Regular 

Partial 

Well 

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day  after  admis- 
sion. 

55 

14  mos. 

No  disease 

Varioloid 

Home 

After 

3 

Regular 

10 

40 

56 

19  yrs. 

Varioloid 

Home 

Before 

Regular 

11 

Well 

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11 

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57 

20  mos. 

Varicella 

Hospital 

After 

2 

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29 

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hours  after  admis- 

sion. 

Sent  as  smallpox; 

58 

28  yrs. 

Measles 

Hospital 

After 

2 

Typical 

Perfect 

12 

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hours  after  admis- 

sion. 

59 

7 yrs. 

No  disease 

Varioloid 

Home 

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12 

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44 

6u 

19  mos. 

No  disease 

Home 

After 

Regular 

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44 

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... 

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... 

14 

hours  after  admis- 

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Vaccinated  a few 

62 

16  mos. 

No  disease 

Home 

After 

2 

Typical 

Perfect 

20 

hours  after  admis- 
sion. 

63 

19  yrs. 

Measles 

... 

Hospital 

After 

4 

Regular 

ab’t 

8 

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14 

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64 

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Home 

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6 

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65 

4 yrs. 

No  disease 

Varioloid 

Horae 

After 

Fair  but 
tardy 

10 

Partial 

31 

day  after  admis- 
sion. 

66  5 rnos. 

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Home 

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14 

Well 

marked 

34 

67 

3 mos. 

No  disease 

Home 

Before 

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16 

68 

3 yrs. 

Varioloid 

Home 

Before 

2 

Regular 

9 

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14 

69 

12  yrs. 

Varioloid 

Home 

Before 

Regular 

7 

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14 

The  eruption  con- 

70 

7 yrs. 

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Home 

Before 

2 

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9 

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14 

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marked 

small  vesicles. 

71 

22  yrs. 

Varioloid 

... 

Home 

Before 

Regular 

10 

Partial 

27 

72 

10  yrs. 

Varioloid 

Home 

Before 

1 

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10 

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9 

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light. 

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about  14  days  no- 
ticed a very  few 

73 

3 mos. 

... 

Home 

After 

1 

Regular 

31 

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sick. 

74 

18  mos. 

Varioloid 

... 

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Before 

Regular 

8 

Well 

marked 

10 

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Sent  to  hospital  as 

75 

8 mos. 

Varicella 

Hospital 

After 

Regular 

Perfect 

None 

Died 

13 

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nated the  day 
after  admission. 

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6 

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Home 

Before 

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6 

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18 

78 

20  yrs. 

Variola 

Home 

B'-fore 

1 

Regular 

3 

None 

Died 

11 

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80 

26  yrs. 

Roseola 

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After 

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26 

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81 

7 yrs. 

Variola 

Home 

Before 

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2 

None 

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6 

82 

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Varicella 

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11 

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Variola 

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... 

85 

4 mos. 

No  disease 

Home 

After 

2 

Typical 

Perfect 

19 

86 

7 wks. 

Erythema 

Hospital 

After 

... 

Regular 

Perfect 

14 

Sent  to  hospital  as  a 
case  of  smallpox. 

87 

11  mos. 

No  disease 

Variola 

Home 

After 

Regular 

7 

None 

28 

88 

2 yrs 

No  disease 

Variola 

Home 

After 

Regular 

5 

None 

Died 

14 

Sent  as  smallpox. 

Was  exposed  24 

89 

21  yrs. 

Varicella 

Variola 

Hospital 

After 

Fair  but 
tardy 

11 

None 

44 

hours  before  vac- 
cinated. Possibly 
the  disease  was 

slightly  modified. 

90 

8 mos. 

Variola 

Home 

Before 

Regular 

7 

None 

Died 

4 

The  eruption  scarce- 

91 

8 mos. 

Varioloid 

... 

Home 

Before 

Regular 

12 

Almost 

perfect 

6 

ly  progressed  be- 
yond the  papular 

stage. 

92 

28  yrs. 

Variola 

Home 

Before 

Regular 

3 

None 

Died 

6 

93 

6 yrs. 

Varioloid 

Home 

Before 

1 

Regular 

9 

Partial 

12 

Came  with  its  moth- 

94 

1 yr. 

No  disease 

Varioloid 

Home 

After 

1 

Regular 

7 

Partial 

... 

31 

er  who  had  vario- 
loid; was  still 
nursing. 

95 

2 yrs. 

Varioloid 

Home 

Before 

1 

Regular 

9 

Partial 

12 

... 

96 

23  yrs. 

Variola 

... 

Home 

Before 

Regular 

4 

None 

Died 

5 

97 

7 mos. 

Variola 

... 

Home 

Before 

Fair 

4 

None 

31 

98 

6 yrs. 

Variola 

... 

Home 

Before 

Fair 

4 

None 

31 

99 

8 yrs. 

Variola 

Home 

Before 

Fair 

4 

None 

31 

The  four  ' last  cases 

belonged  to  one 

100 

14  yrs. 

Variola 

Home 

Before 

Fair 

4 

None 

31 

fa  m i 1 y.  All  ad- 
mitted on  the  14th 

day  eruption. 

101 

29  yrs. 

Variola 

Home 

Before 

Regular 

10 

None 

61 

Corneal  ulcer  devel- 
oped. 

102 

4 yrs. 

Variola 

Home 

Before 

Regular 

4 

None 

37 

lu3 

2 yrs. 

Variola 

... 

Home 

Before 

Tardy 

7 

None 

Died 

2 

Hemorrhagic. 

104 

8 yrs. 

Variola 

Home 

Before 

Regular 

5 

None 

26 

105 

5 yrs. 

Variola 

Home 

Before 

Fair 

6 

None 

14 

Possibly  the  disease 

was  slightly  modi- 

106 

7 yrs. 

Varicella 

Variola 

Home 

Before 

Tardy 

11 

None 

35 

tied.  Sent  to  hos- 

pital  as  a case  of 
smallpox. 

There  being  small- 

pox  in  the  fam- 

107 

24  yrs. 

Roseola 

vaccinosa 

Home 

Before 

Typical 

Perfect 

3 

ily,  this  peculiar 
eruption  was  mis- 

taken  for  that  dis- 

108 

13  yrs. 

Variola 

Home 

Before 

Fair  but 
tardy 
Fair 

6 

None 

Died 

6 

ease. 

Hemorrhagic. 

109 

11  yrs. 

Variola 

Home 

Before 

6 

None 

Died 

14 

Hemorrhagic. 

hs 

Not  more  than  two 

dozen  small  vario- 
lous vesicles  ap- 

110 

1 yr. 

Varioloid 

... 

Home 

Before 

Regular 

13 

Almost 

perfect 

20 

peared,  and  ran  a 
very  short  course. 
There  was  no  well- 

marked  febrile 
stage. 

166 


•3 

3 

3 

Age. 

Disease  Admitted  with. 

Disease  Developing  in 
Hospital. 

Where  Exposure  First 
Took  Place. 

Vaccinated  Before  or  After 
Admission. 

No.  of  Insertions. 

.11 

3 wks. 

No  disease 

Very  mild 
varioloid 

Home 

After 

.12 

27  yrs. 

Variola 

Home 

Before 

113 

3 yrs. 

V arieella 

Variola 

Hospital 

After 

2 

114 

5 mos. 

No  disease 

Home 

Before 

115 

11  yrs. 

No  disease 

Varioloid 

Home 

After 

116 

1 yr. 

No  disease 

Varioloid 

Home 

Before 

117 

35  yrs. 

Variola 

Home 

Before 

118 

5 yrs. 

No  disease 

Varioloid 

Hospital 

After 

3 

119 

4 yrs. 

No  disease 

Hospital 

After 

3 

120 

lyf. 

Pertussis 

Variola 

Home 

After 

3 

121 

1 yr. 

No  disease 

Varioloid 

Home 

After 

122 

6 yrs. 

Variola 

Home 

Before 

1 

123 

11  yrs. 

Variola 

Home 

Before 

1 

124 

4^ 

mos. 

Varioloid 

Home 

Before 

1 

125 

1 1 yrs. 

Variola 

Home 

Before 

126 

9 mos. 

No  disease 

Variola 

Home 

After 

1 

127 

128 

3 yrs. 

Variola 

Home 

Before 

18  yrs. 

Variola 

Home 

Before 

129 

5 yrs. 

Variola 

Home 

Before 

130 

33hrs. 

No  disease 

Varioloid 

Home 

After 

0 

131 

13  mos. 

Varioloid 

Home 

Before 

132 

23  yrs. 

No  disease 

Variola 

Hospital 

After 

2 

133 

12  yrs. 

Varioloid 

Home 

Before 

134 

10  mos. 

No  disease 

Varioloid 

Home 

After 

1 

135 

2 yrs. 

Measles 

Varioloid 

Hospital 

After 

2 

aJ 

> , 


ca 

u 

cs 

ja 

U 


Regular 

Regular 

Fair  but 
tardy 

Typical 

Fair  but 
tardy 


Typical 

Fair 

Regular 

Regular 

Fair  but 
tardy 

A little 
tardy 

Fair  but 
tardy 

Regular 

Regular 


Regular 

Tardy 

Fair 

Regular 

Tardy 


Regular 


Fair 


Fair  but 
tardy 

Regular 

* 

Regular 


Regular 


a>  cu 

-a  £ 

s S 

•a  5- 

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a ^ 

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a a 

> 2 

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<*-  -T 

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10 


o 

IH 

Ph 


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a> 

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Almost 

perfect 

None 

None 

Perfect 

Well 

marked 


Almost 

perfect 


None 

Well 

marked 


Perfect 


None 

Almost 

perfect 

None 

None 


Well 

marked 


None 

None 

None 

None 

None 


Well 

marked 


19 

46 

34 

24 

29 


19 


Died  20 
50 

50 


Died 


Died 


Died 


Died 


Partial  Died 


Scarcely 

any 


Well 

marked 

Well 

marked 


Well 

marked 


Died 


43 

36 

16 

36 

32 


12 


Remarks. 


8 variolous  vesicles 
appeared. 

If  there  were  any 
modification  it 
was  slight. 


About  half-dozen 
small  v ari o 1 ous 
vesicles  appeared 
without  any  pre- 
vious febrile  stage. 
The  variolous 
eruption  devel- 
oped in  advance 
of  the  vaccine  ves- 
icle. 

Died  of  pneumonia. 

Eruption  very  light. 
Child  not  confined 
to  bed. 

A very  few  papules 
were  noticed,  but 
they  soon  disap- 
peared. No  febrile 
disturbance. 

The  eruption  con- 
sisted of  only  2 or 
3 vesicles. 


The  variolous  erup- 
tion consisted  of 
only  two  dozen 
small  vesicles. 
The  health  of  the 
child  was  appa- 
rently not  dis- 
turbed. 


Bottle  fed  baby. 
Very  feeble.  Only 
14  variolous  pap- 
ules. Would 
scarcely  have 
lived  anyhow. 

Disease  apparently 
modified.  Death 
was  caused  by  gas- 
trointestinal dis- 
order 

Vaccinated  at  first 
with  bovine  virus 
and  on  the  follow- 
ing day  with  hu- 
manized. 

Died  during  conva- 
lescence from  en- 
tero-colitis. 

Sent  to  hospital  as  a 
case  of  smallpox. 
In  the  hospital 
only  15  days 
counting  from  the 
beginning  of  erup- 
tion. 


107 


168 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


U 

■a  x5 
© © 

£ 

a 

00 

G 

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-a 

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a 

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m 

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£■ 
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o 

"a. 

Number. 

Age. 

'd 

$ 

-3 

■ia 

a 

'd 

< 

© 

CO 

CJ 

© 

isease  Developii 
Hospital. 

here  Exposure 
Took  Place. 

dnated  Before  o 
Admission. 

No.  of  Insertio 

baracter  of  Va< 
Vesicles. 

a a 

•3.2 
© «- 
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© 

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£ 

o 

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H 

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Deaths  Noted 

o 

X 

co 

C5 

G 

•— 

o 

Remarks. 

3 

P 

CJ 

p 

6 

55 

> 

O as 

136 

23  yra. 

Varioloid 

Home 

Before 

1 

Regular 

10 

Partial 

40 

Vaccinated  with  bo* 
vine  virus. 

137 

8 yrs. 

Variola 

Home 

Before 

Fair 

6 

None 

Died 

2 

138 

17  mos. 

Variola 

... 

Home 

Before 

Fair 

4 

None 

36 

139 

5 wks. 

Not  sick 

Variola 

Home 

After 

Regular 

2 

None 

Died 

14 

The  first  vaccination 
failed  to  take. 
There  was  but  lit- 

tie.  if  any,  febrile 

140 

6 mos. 

No  disease 

Varioloid 

Hospital 

After 

Regular 

14 

Almost 

perfect 

26 

disturbance,  and 
only  a dozen  pap- 
ules, which  be- 

came  barely  ves- 

141 

4 yrs. 

Varioloid 

Home 

Before 

Regular 

8 

Well 

marked 

26 

icular. 

Perhaps  the  attack 

142 

3 yrs. 

Variola 

Home 

Before 

Regular 

7 

None 

33 

was  slightly  mod- 
ified. 

The  eruption  was 

143 

4 mos. 

No  disease 

Varioloid 

Home 

Before 

1 

Fair  but 
tardy 

11 

Well 

marked 

... 

27 

light,  and  desieca- 
tio  d occu  rred 
early. 

144 

6 mos. 

No  disease 

Hospital 

After 

4 

Regular 

Perfect 

18 

DISCUSSION. 

Dr.  Carter  inquired  how  Dr.  Welch  knew  that  his  patients  would  have  had 
variola  at  all,  if  they  had  not  been  vaccinated. 

Dr.  Cundell-Juler,  Cincinnati,  Ohio,  was  led  by  observation  to  believe  with 
the  essayist  that  a greater  immunity  from  smallpox  was  enjoyed  by  him  who  had 
been  vaccinated  in  early  life  from  the  mature  vaccine  vesicle  than  would  be  assured 
by  vaccination  from  the  crust  that  fell  from  the  arm  at  the  fourteenth  day  after  the 
operation. 

He  referred  to  the  experience  he  had  when  district  vaccinator  and  in  hospital 
practice  in  England.  He  spoke  of  the  care  observed  and  the  method  of  vaccinating 
in  that  country,  and  also  of  the  method  adopted  in  the  United  States.  Like  himself, 
there  were  many  physicians  who,  when  infants,  had  been  vaccinated  from  the  vaccine 
vesicle,  who  had  stood  by  the  bedside  of  smallpox  patients  and  been  exposed  to  the 
contagion  in  many  and  various  ways,  who  had  never  been  revaccinated,  and  yet 
escaped  the  malady. 

Dr.  William  Knight,  of  Cincinnati,  Ohio,  said — Vaccination  in  the  incubation 
stage  of  variola  is  not,  in  my  opinion,  as  efficacious  as  inoculation. 

In  an  instance  that  occurred  in  my  practice  an  unvaccinated  woman  in  the  ninth 
month  of  pregnancy  was  attacked  with  confluent  variola.  During  the  second  stage 
of  the  disease  I delivered  her  of  a child.  Lying  in  the  same  bed  was  her  son,  three 
years  of  age,  who  had  not  been  vaccinated.  I at  once  inoculated,  from  a pustule  in 
the  mother,  both  the  boy  and  the  newly-born  infant.  The  boy  had  a mild  attack  of 
variola,  leaving  but  few  cicatrices.  The  mother  died  on  the  third  day  after  her 
confinement.  The  infant  died  about  the  same  time,  showing  no  signs  of  the 
affection. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


1G9 


I mention  this  instance  as  affirinatory  of  my  view  that  iuoculation  is  preferable 
to  vaccination  as  a prophylactic  in  the  incubation  stage  of  smallpox. 

Dr.  Gottheil,  of  New  York,  had  had  occasion  to  see  large  numbers  of  vaccina- 

• tions  in  some  of  the  public  institutions  of  that  city.  Every  patient  admitted  was 

■ vaccinated,  even  if  the  operation  had  been  done  repeatedly  and  but  a short  time 
before.  Few  were  successful;  but  as  a rule  the  so-called  “raspberry”  excrescence 
was  of  very  frequent  occurrence  indeed.  These  he  had  always  regarded  as  the  exu- 
berant granulations  of  a weak  ulcer;  but  he  would  like  to  know  whether  the  condi- 
tion resulted  from  the  action  of  the  virus  upon  a soil  already  exhausted,  or  whether 
it  was  due  to  some  special  quality  of  the  vaccine. 

Dr.  Rogers  Parker,  of  Liverpool,  England,  a public  vaccinator  for  the  city  of 
Liverpool,  said  that  in  the  large  cities  of  England  human  lymph  was  usually  employed. 

I Large  vaccination  stations  were  established,  to  which  the  parents  were  required  to 
oring  the  children  at  certain  times,  and  the  children  vaccinated  one  week  returned 
lpon  the  same  day  the  next  week,  so  that  there  was  always  an  abundance  of  vesicles 
?rom  which  to  choose  in  vaccinating  the  others.  Revaccination  is  not  compulsory, 

• out  was  usually  done  in  schools  and  public  bodies  at  about  the  age  of  fourteen.  He 
jelieves  humanized  virus  gives  better  protection  thau  animal  virus. 

Dr.  Keller,  of  Hot  Springs,  Ark. , related  an  incident  of  war  times.  He  was 
n charge  of  a hospital  on  the  Southern  side.  An  epidemic  of  variola  broke  out.  A 
supply  of  lymph  was  received,  with  information  that  it  came  from  the  North,  and 
I ,vas  suspected  of  being  poisoned.  Such  stories  were  then  current.  He  decided  to 
lse  it,  and,  to  avoid  error,  divided  each  point,  vaccinating  a citizen  with  one  part 
ind  a soldier  with  the  other.  Nine-tenths  of  the  soldiers  had  unhealthy  sores  fol- 
owing  the  operation,  but  none  of  the  citizens,  showing  that  they  were  due  to  the 
v scorbutic  condition  of  the  soldiers,  and  not  to  impure  virus. 

Dr.  Yeamans,  of  Detroit,  Mich.,  said  his  belief  in  the  protective  power  of  vac- 
i lination,  after  exposure  had  occurred,  grew  yearly  less  and  less.  He  had  had 
considerable  experience  in  the  matter,  and  thought  we  lost  sight  of  the  many  other 
nfluences  brought  to  bear  which  may  modify  the  case  under  observation. 

Dr.  Robinson,  the  President,  asked,  if  vaccinia  is  an  infectious  disease,  depend- 
' ng  upon  organisms  which  multiply  with  enormous  rapidity  and  exist  in  the  system 
< is  long  as  suitable  material  is  present,  why  more  than  one  point  of  inoculation  is 
f<  considered  necessary.  If  unnecessary,  multiple  scarifications  should  not  be  made,  on 
; recount  of  the  scar  deformity  resulting.  He  would  not  make  more  than  one  point 
if  inoculation  except  during  the  incubation  period  of  variola,  or  exposure  to  the 
8 disease. 

Dr.  Lathrop,  of  Dover,  N.  H. , believed  that  he  had  seen  vaccinia  take  the 
place  of  smallpox. 

Dr.  Welch,  in  closing,  said  he  had  been  skeptical  in  regard  to  the  necessity  for 
multiple  inoculations,  and  believed  one  typical  cicatrix  gave  as  good  protection  as 
i many.  Animal  virus,  or  virus  of  recent  humanization,  gives  a more  durable  protec- 
tion. That  of  long  humanization  produces  a more  superficial  scar,  and  deaths  were 
more  frequent  in  those  showing  superficial  scars.  He  does  not  believe  in  life-long 
protection  of  vaccination.  The  ulcers  mentioned  by  Dr.  Gottheil  he  thought  were 
' only  found  after  animal  lymph  had  been  used.  It  is  not  true  vaccination,  and  it 

■ gives  no  protection. 


170 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


RECTAL  ALIMENTATION  AND  MEDICATION  IN  DISEASES 

OF  THE  SKIN. 

ALIMENTATION  PAR  RECTUM,  ET  MEDICATION  DANS  LES  MALADIES  DE 

LA  PEAU. 

UBER  ERNAHRUNG  UND  MEDICATION  PER  RECTUM  BEI  HAUTKRANKHEITEN. 

BY  JOHN  Y.  SHOEMAKER,  A.M.,  M.D., 

Of  Philadelphia. 

The  power  of  the  rectal  mucous  membrane  to  absorb  substances  placed  in  contact 
with  it  is  but  little  inferior  to  that  of  any  other  portion  of  the  gastro-intestinal  canal. 

Moderate  quantities  of  milk,  eggs,  gruel,  beef  tea  and  all  the  nutritious  broths  are 
absorbed  by  the  rectum  almost  as  quickly  as  by  tbe  stomach.  Ether  and  other  volatile 
agents  produce  their  characteristic  effects  immediately  after  their  introduction  into  the 
rectum.  Solutions  of  morphia,  atropia,  aconitia,  quinia  and  hyoscyamia  are  taken 
up  as  rapidly,  and  strychnina  and  nicotine  more  rapidly,  by  it  than  by  the  stomach. 

As  a general  rule  all  substances  in  solution  are  speedily  absorbed  by  the  rectum 
unless  they  are  so  irritative  in  character  as  to  produce  muscular  contraction,  which  wiil 
only  cease  upon  their  expulsion.  Soluble  non-irritating  substances  in  powder  or  in  the 
form  of  suppositories  are  taken  up  more  slowly,  but  eventually  as  certainly,  as  if  admin- 
istered in  the  usual  manner,  unless  expelled  along  with  the  faeces  before  absorption  is 
complete.  The  absorbent  properties  of  the  rectum  are  frequently  availed  of  in  the 
treatment  of  gastric  irritability,  ulcer  of  the  stomach,  carcinoma  of  various  portions  of 
the  alimentary  tract.  By  giving  the  stomach  absolute  rest,  and  nourishing  and  medi- 
cating the  patient  by  the  rectum,  the  duration  of  acute  attacks  is  lessened,  life  in  many 
cases  saved,  and  in  others  prolonged  for  months. 

The  same  methods  which  yield  such  gratifying  results  in  these  diseases  may  also  be 
employed  with  decided  benefit  in  many  cutaneous  affections. 

In  epithelioma  of  the  lips  and  tongue,  after  excision  has  been  performed  patients 
are  usually  fed  through  a rubber  tube,  but  notwithstanding  the  greatest  care  on  the  part 
of  the  patient  and  nurse,  the  movement  of  the  muscles  in  swallowing  conveys  more  or 
less  irritation  to  the  edges  of  the  wound,  and  may,  in  some  cases,  stimulate  the  morbid 
process  to  renewed  activity.  It  would  be  much  better  in  such  cases  to  place  the  oral 
muscles  at  complete  restand  nourish  the  patient  by  the  rectum  until  the  wound  is  com- 
pletely healed.  The  same  method  should  be  adopted  for  several  days  after  cauterizing 
or  scraping  lupus  spots  on  the  lips  or  in  the  mouth. 

In  stubborn  cases  of  infantile  eczema,  in  which  the  little  patient  while  retaining  all 
the  food  it  takes,  and  presenting  no  symptoms  of  gastro-intestinal  disorder,  yet  does  not 
increase  in  weight,  immediate  improvement  will  often  follow  the  administration  of  one 
ounce  of  milk  enema  four  times  a day.  In  these  cases,  which  may  be  termed  examples 
of  infantile  apepsia,  the  skin  affection  is  clearly  the  result  of  insufficient  nutrition. 

Obstinate  cases  of  pemphigus  and  impetigo  in  children  of  all  ages  are  frequently  due 
to  the  same  cause,  and  are  promptly  relieved  as  soon  as  supplementary  rectal  nutrition 
compensates  for  deficient  gastric  assimilation. 

There  is  an  intractable  form  of  recurrent  acne  observed  in  young  girls  and  delicate 
boys,  which,  on  inquiry,  will  be  found  to  be  closely  associated  with  stomachic  debility. 
When  their  appetite  is  good  and  digestion  perfect  the  eruption  disappears,  but  after  a 
time,  without  apparent  cause,  their  appetite  lessens,  the  sight  or  smell  of  food  produces 
a feeling  of  nausea,  and  if  they  force  themselves  to  eat  as  much  as  formerly,  they  vomit 
it  soon  afterward.  They  become  pallid  and  weak,  and  the  eruption,  usually  consisting 
of  from  one  to  a dozen  papules,  reappears.  Investigation  fails  to  disclose  the  portion  of 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


171 


the  digestive  system  at  fault.  The  tongue  remains  clean,  the  bowels  are  normal,  and  all 
the  bodily  functions,  except  those  of  eating  and  assimilating,  are  performed  as  usual.  The 
routine  treatment  for  these  patients  consists  of  iron,  strychnine,  the  mineral  acids,  and 
various  bitter  tonics,  and  usually  terminates  in  success  in  from  two  to  six  months. 
Many  of  them  could  be  cured  in  from  two  to  four  weeks  by  combining  the  rectal  admin- 
istration of  milk,  malt  extract,  and  beef  juice  with  the  internal  medication  previously 
referred  to. 

A general  rule,  which  may  be  safely  followed  in  the  treatment  of  all  diseases, 
whether  of  the  skin  or  any  other  organ  or  portion  of  the  body  is  — 

Whenever  the  system  manifests  evidences  of  insufficient  nutrition,  supplement 
stomachic  assimilation  by  the  administration  of  nutritious  enemata. 

The  only  exception  to  this  rule  is  when  the  rectum  is  unable,  either  from  irritability 
or  disease,  to  retain  the  enema  long  enough  for  absorption  to  occur. 

Care  should  be  taken  in  the  preparation  of  nutritious  enemas  to  ensure  their  reten- 
tion. If  too  large  they  will  over-distend  the  rectum,  and  produce  vigorous  contractions 
ending  in  expulsion.  If  too  cold  or  too  hot  the  same  result  will  also  occur.  They 

- should  be  lukewarm  and  not  exceed  four  ounces  for  an  adult,  and  one  ounce  and  a half 
for  a child.  They  ought  not  to  be  given  oftener  than  once  every  four  hours,  or  they 
may  induce  an  irritable  condition  of  the  mucous  membrane.  The  advice  of  some 
authors  to  empty  the  rectum  of  fecal  matter  by  an  ordinary  injection  before  giving  an 
enema  intended  for  absorption  is  ludicrous.  Every  surgeon  knows  that  the  rectum,  as 

^ was  pointed  out  by  O'Byrne,  forty  years  ago,  is  normally  an  empty  pouch  until  defeca- 
tion begins. 

Rectal  Medication. — In  cutaneous  diseases  suppositories  are  the  most  convenient 
form  of  medicating  the  system  by  the  rectum.  They  are  absorbed  more  slowly  than 
solutions,  but  their  ease,  cleanliness  and  safety  of  administration  more  than  compen- 
sate for  their  slightly  retarded  action.  They  are  especially  valuable  in  the  treatment 
of  those  phenomenal  children  who  have  an  invincible  repugnance  for  medicine  in  any 
form,  and  who  manage  to  spit  it  out  or  vomit  it  up,  notwithstanding  all  sorts  of  threats 
and  caresses.  Medicated  suppositories  will,  in  these  cases,  relieve  the  parents  as  well  as 
the  patient,  and  make  the  doctor’s  life  more  bearable.  The  main  indication  for  rectal 
medication  in  cutaneous,  as  well  as  other  diseases,  is  inability  of  the  stomach  to  receive 
or  retain  the  medicines  needed  to  restore  health.  As  this  is  the  only  criterion,  it  is 
obvious  that  it  would  be  impossible  to  enumerate  the  affections  of  the  skin  in  which 
rectal  medication  would  be  valuable  and  those  in  which  it  would  be  useless.  Every 
case  must  be  judged  in  accordance  with  its  own  requirements. 

If  the  symptoms  present  are  such  as  are  usually  antagonized  or  removed  by  the  sys- 
temic action  of  a certain  drug,  and  the  gastric  mucous  membrane  is  so  disordered  that 
1 that  drug  is  immediately  rejected  by  vomiting,  our  duty  is  to  endeavor  to  procure  its 
absorption  in  another  manner,  rather  than  to  discard  it  and  search  for  another  remedy. 

In  many  cases  of  syphiloderma  mercury  will  not  be  tolerated  by  the  stomach,  and 
the  patient's  habits  or  business  affairs  are  such  that  inunctions,  hypodermatic  injections 
or  fumigations  cannot  be  employed.  In  these  cases  I have  repeatedly  witnessed  the 
disappearance  of  the  eruption,  and  the  recovery  of  the  patient,  from  the  employment 
i twice  a day  of  suppositories  containing  one-half  grain  of  calomel  or  one-quarter  grain 
of  the  protiodide  of  mercury.  Infantile  syphilis  may  be  effectually  treated  iu  the 
1 same  way,  reducing  the  quantity  of  calomel  to  the  one-twelfth  of  a grain,  and  the  prot- 
' iodide  to  the  one-twentieth  or  the  one-hundredth  part  of  a grain.  The  bichloride  or 
any  of  the  other  preparations  of  mercury  may  be  substituted  in  appropriate  doses. 

Scrofuloderma  is  almost  invariably  benefited  by  cod-liver  oil,  but  patients  are  occa- 
sionally met  with  who  are  unable  to  take  it  in  any  form.  In  two  mild  cases  of  this 

- disease  under  my  care  receutly,  in  which  this  idiosyncrasy  was  extreme,  I effected  com- 


172 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


plete  cures  by  the  employment  of  rectal  enemas  of  one  ounce  of  cod-liver  oil  every 
night,  continued  for  five  weeks  in  one  case  and  in  the  other  for  two  months. 

Erythema  multiforma  and  erythema  nodosum,  when  due  to  malaria,  are  usually 
accompanied  by  so  much  gastric  irritability  that  even  water  is  vomited  as  soon  as  it 
reaches  the  stomach.  Twenty  grains  of  quinine  made  into  a suppository  and  inserted 
in  the  rectum  will  relieve  all  the  symptoms  in  a few  hours. 

Urticaria  nodosum,  a somewhat  similar  affection,  will  promptly  yield  to  the  same 
treatment.  Urticaria  simplex,  due  to  the  presence  of  fermentative  or  irritating  mate- 
rial in  the  gastro-iutestinal  canal,  can  be  more  speedily  relieved  by  the  rectal  injection 
of  an  ounce  of  castor  oil  and  an  ounce  of  glycerine  than  by  any  other  method. 

Erythema  intertrigo,  when  produced  by  the  irritation  of  diarrhceal  discharges,  can 
frequently  be  removed  almost  immediately  by  the  use  of  a single  suppository  contain- 
ing a small  quantity  of  opium  combined  with  from  five  to  twenty  grains  of  a vege- 
table astringent  like  geranium  or  hamamelis. 

Pruritus  ani  is  often  due  to  an  cedematous  condition  of  the  tissues  around  the  anus. 
In  this  event  anti-pruritic  lotions  and  ointments  can  be  of  only  temporary  utility,  and 
occasionally  aggravate  instead  of  alleviating  the  patient’s  sufferings.  A suppository 
containing  ten  grains  of  powdered  geranium,  or  ten  grains  of  quercus  alba,  will  dissi- 
pate the  oedema  and  banish  the  itching.  Pruritus  vulvae  and  general  pruritus  are  occa- 
sionally traceable  to  disorder  of  the  anal  nerves,  and  can  then  be  almost  magically 
relieved  by  the  employment  of  suppositories  composed  of  opium  £ gr.  and  extract  of 
belladonna  \ gr.  Opium  1 gr.  and  chloral  5 grs.,  quinine  10  grs.  and  extract  of  cannabis 
indica  \ gr.  is  also  useful.  Arsenic  and  antimony  are  of  incalculable  benefit  in  many 
cases  of  psoriasis,  but  they  frequently  disorder  the  stomach  so  much  that  their  admin- 
istration is  suspended  before  the  eruption  is  removed,  and  some  less  potent  but  less 
irritating  remedies  substituted.  My  experience  has  convinced  me  that  to  discontinue 
their  use  under  such  circumstances  is  an  error.  They  can  be  given  with  advantage  in 
the  form  of  suppositories.  Care  must  be  taken,  however,  to  have  them  evenly  divided 
throughout  the  mass,  and  to  employ  at  least  grain  of  arsenious  acid  or  arsenite  of 
sodium  in  each  suppository,  one  to  be  used  from  one  to  five  times  a day.  Iodide  of 
potassium  is  of  great  service  in  many  cases  of  subacute  and  chronic  eczema,  but  its 
peculiar  recurrent  taste  and  the  additional  eruption  which  is  occasionally  developed  by 
it  limits  its  employment.  If  it  be  given  in  small  doses  in  the  form  of  suppositories,  these 
unpleasant  drawbacks  will  rarely  be  observed. 

There  are  other  cases  of  obstinate  eczema  in  which  rectal  enemata  of  cod-liver  oil 
will  be  more  successful  than  any  other  remedy.  Ichthyosis  may  be  signally  palliated 
by  the  same  method. 

Many  other  cutaneous  affections  might  be  mentioned  in  which  rectal  medication 
will  prove  valuable,  but  I prefer  to  limit  my  remarks  to  those  in  which  I have  realized 
its  value  by  practical  experience. 


DISCUSSION. 

Dr.  P.  G.  UNNA,  of  Hamburg,  Germany,  agreed  with  the  reader  of  the  paper  in 
the  good  effects  obtained  by  rectal  medication  in  many  affections.  He  asked  concern- 
ing the  experience  of  the  author  in  regard  to  the  administration  of  mercury  ; whether 
diarrhoeas  and  other  unfortunate  effects  were  not  likely  to  occur. 

Dr.  Klotz,  of  New  York,  expressed  his  doubt  that  the  absorbent  power  of  the 
rectum  should  be  found  to  be  unimpaired  under  conditions  where  resorption  by  the 
gastric  mucous  membrane  and  the  rest  of  the  digestive  canal  is  undoubtedly  dimin- 
ished, for  instance,  in  fever.  This  is  said  in  regard  to  certain  diseases  mentioned 
by  Dr.  Shoemaker,  as,  for  instance,  pemphigus  acutus  in  small  children,  which  he 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


73 


admits  is,  as  a rule,  an  acute,  probably  infectious  disease,  accompanied  by  more  or 
less  fever. 

In  closing,  Dr.  Shoemaker  replied  to  Dr.  Unna’s  question,  that  when  the  mer- 
curial was  given  first  in  small  doses  and  gradually  increased,  the  good  effects  were 
a secured  and  the  ill  effects  obviated. 


ON  THE  OCCURRENCE  OF  ULCERS  RESULTING  FROM  SPONTA- 
NEOUS GANGRENE  OF  THE  SKIN  DURING  THE  LATER 
STAGES  OF  SYPHILIS,  AND  THEIR 
RELATION  TO  SYPHILIS. 

Sl'R  L’OCCURRENCE  DES  ULCERES  RESULTANT  DE  LA  GANGRENE  SPONTANEE 
I)E  LA  PEAU  PENDANT  LE  DERNIER  PERIODE  DE  LA  SYPHILIS, 

ET  LEUR  RAPPORT  AVEC  LA  SYPHILIS. 

UBER  DAS  VORKOMMEN  VON  GESCHWUREN  IN  FOLGE  VON  SPONTANER  GANGRANE 
DER  IIAUT  IN  DEN  SPATEREN  STADIEN  DER  SYPHILIS,  UND  IHRE 
BEZIEHUNG  ZU  DERSELBEN. 

BY  HERMANN  G.  KLOTZ,  M.D., 

Of  New  York. 

"Whenever  we  find  an  ulcer  of  round  or  oval  shape,  sharply  cut  as  if  punched  out, 

I with  somewhat  thickened,  abrupt  edges,  extending  deeply  into  or  through  the  entire 
thickness  of  the  skin,  with  an  uneven  floor  of  a dark-green  or  yellow,  dirty  color,  in 
a person  known  to  he  under  the  influence  of  syphilis  in  its  later  stages,  such  an  ulcer 
; we  generally  consider  to  be  a syphilitic  one — that  is  to  say,  to  owe  its  origin  to  necrosis 
( of  some  previously  formed  specific  tissue,  most  frequently  to  the  breaking  down  of  a 
gummatous  infiltration.  An  observation  made  several  years  ago  rendered  it  more  than 
probable  to  me  that  similar  ulcers  in  syphilitic  persons  might  directly  result  from  cir- 
cumscribed spontaneous  gangrene  of  the  skin,  due  to  syphilitic  arteritis  or  endarteritis 
obliterans. 

Among  the  patients  who  came  under  my  care  when,  on  July  1st,  1879,  I took  charge 
of  the  outdoor  poor  service  of  the  German  Society  of  New  York,  was  Mrs.  S.,  fifty- 
eight  years  of  age,  who,  while  otherwise  in  good  health  and  strength  and  able  to  attend 
to  her  household  duties,  was,  owing  to  a sore  leg,  prevented  from  leaving  the  house. 

I Beginning  directly  below  the  knee,  the  right  leg  was  considerably  enlarged  ; on  its 
upper  two-thirds  the  skin  was  congested  and  shining,  showing  numerous  dilated  blood 
' vessels,  but  was  otherwise  in  good  condition.  From  about  the  lower  third  of  the  leg  to 
the  middle  of  the  dorsal  aspect  of  the  foot,  ulcers  of  irregular  shape,  at  least  one  cen- 
I timetre  deep,  with  sharply  cut,  indurated  edges,  occupied  nearly  the  entire  circumfer- 
ence of  the  ankle.  The  floor  of  the  ulcers  showed  an  uneven  surface,  of  a dirty  green 
; color,  furnishing  a copious  watery  discharge  of  very  offensive  odor.  The  foot,  with  the 
exception  of  the  toes,  was  enormously  enlarged  in  consequence  of  swelling  of  the  soft 
parts,  principally  of  the  skin,  which  was  partly  smooth  and  glistening,  partly  uneven, 

' owing  to  the  formation  of  numerous  aggregated  wart-like  elevations,  and  was  kept 
i constantly  moist  by  a watery  secretion.  At  first  sight  the  case  seemed  to  be  one  of 
1 simple  chronic  ulcers  with  elephantiasis  of  the  leg  ; closer  examination  of  the  patient, 
however,  made  it  more  than  probable  that  syphilis  was  at  the  bottom  of  the  disease. 


174 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  patient  being  almost  deaf  and  not  of  very  bright  intellect,  it  was  with  some 
difficulty  that  the  following  history  was  extracted  : Her  husband  is  living,  and  does 

not  show  any  signs  of  disease  ; she  has  two  grown-up  sons,  both  iu  good  health;  she 
herself  was  strong  and  healthy  until  eight  years  ago,  when  a tumor  formed  over  the 
sternum,  which,  without  ever  causing  much  pain,  broke  and  left  an  extensive  ulcer 
which  finally  healed.  Soon  after  similar  ulcers  developed  on  the  dorsal  side  of  the 
right  forearm,  which  likewise  healed.  Only  a few  weeks  later  ulcers  made  their  appear- 
ance on  the  back  of  the  right  foot,  laying  bare  the  bones  but  gradually  filling  up  again 
to  about  the  present  state,  never  healing,  but  attaining  by  degrees  their  present  size. 
Extensive,  white,  sharply  defined  scars,  adherent  on  the  sternum,  confirmed  the  patient’s 
report  and  left  little  doubt  as  to  the  syphilitic  character,  particularly  of  that  over  the 
sternal  region,  so  favored  a location  of  syphilis. 

Under  appropriate,  mostly  specific  treatment  the  swelling  of  the  extremity  was 
gradually  reduced,  the  ulcers  themselves  presented  a cleaner,  healthier  aspect,  now  and 
then  good  granulations  cropped  up,  the  edges  had  flattened  down  and  softened  visibly, 
when  on  one  of  my  visits,  iu  November,  I was  surprised  to  find  the  skin  above  the  ankle 
affected  at  several  new  places,  which  before  had  been  smooth  and  but  little  infiltrated. 
Being  interested  in  the  patient,  I had  visited  her  at  least  once  a week,  and  had  watched 
the  progress  closely.  I felt  confident  that  on  the  localities  of  the  recent  affections  no 
swelling,  not  even  any  discoloration,  had  previously  existed.  Now  there  appeared  on 
several  places  dark-green,  oval-shaped  sloughs,  of  about  the  size  of  a small  hen’s  egg, 
surrounded  by  well-defined  borders,  which  were  not  more  congested  or  swollen  than 
the  rest  of  the  skin;  their  appearance  was  accompanied  by  considerable  sharp  pains. 
Gradually  the  tough,  dry  eschars  began  to  separate  from  the  surrounding  tissues  with- 
out losing  their  totality,  showing  an  uneven  floor  throughout,  the  lower  third  of  which 
was  of  semilunar  shape,  level  and  slightly  elevated,  and,  like  the  rest,  coated  by  a thin 
layer  of  yellowish  detritus.  After  a while  the  ulcers  thus  formed  took  on  the  same 
appearance  as  the  old  ones,  making  but  very  slight  progress  toward  improvement, 
without,  however,  evincing  a tendency  to  increase  in  circumference. 

In  September,  1880,  the  patient’s  left  leg,  which  so  far  had  remained  intact,  began 
to  swell  quite  rapidly,  exhibiting  oedema  of  the  soft  parts  with  but  slight  congestion, 
when  an  injudiciously  applied  liniment  caused  a dermatitis  or  artificial  eczema.  This 
had  subsided  when,  in  October,  without  auy  previous  induration  or  circumscribed 
swelling,  similar  sloughs  as  above  described  were  formed  on  the  back  of  the  foot,  fol- 
lowed in  November  by  more  extensive  sloughing  of  the  skin  above  the  left  ankle.  Soon 
after,  symptoms  of  blood  poisoning  set  in,  which  early  iu  December  terminated  iu 
death. 

Here  I had  a patient  of  whose  syphilitic  taint  there  could  be  no  doubt,  with  ulcers 
closely  resembling  the  typical  so-called  gummatous  ulcer  of  syphilis;  still  I felt  abso- 
lutely certain  that  in  those  localities  where  I had  been  able  to  watch  their  development 
there  had  been  no  symptoms  of  previous  gummatous  infiltration.  There  had  been  no 
reddening  of  the  surface,  no  spontaneous  opening  of  a single  aperture  nor  ulceration 
at  several  distinct  points,  no  formation  of  a small,  deep  ulcer  Avith  a core  underneath, 
and  final  extension  until  the  entire  neoplasm  was  destroyed  ; no  thickened  edges  and 
no  hyperajmic  areola.  The  blackish-green  eschars  had  appeared  at  once,  uniformly 
covering  the  Avhole  area;  they  Avere  closely  adherent  at  first  to  the  surrounding  shin, 
Avhich  itself  did  not  exhibit  any  changes  from  its  former  condition  ; they  gradually  sepa- 
rated in  their  totality — clearly  spontaneous  gangrene  of  the  skin.  Iu  looking  for  the 
cause  of  the  gangrene,  there  was  no  evidence  of  trauma,  none  of  tlie  influence 
of  heat  or  cold  or  of  caustic  or  irritating  chemical  action,  none  of  a diathesis 
like  diabetes  or  of  an  infectious  disease,  none  of  neurotic  influences,  none  of  ergot- 
ism, or  any  other  cause  except  obstruction  to  the  circulation.  The  patient  exhibited 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPIIY.  175 

no  signs  of  endocarditis,  no  sclerosis  of  the  arteries  in  other  parts  where  it  usually 
manifests  itself;  therefore  it  seemed  probable  that  syphilitic  arteritis  or  endarteritis 
obliterans  had  led  to  the  interruption  of  circulation.  This  I stated  to  be  my  opinion 
when  I presented  the  patient  at  a meeting  of  German  physicians  of  New  York  in 
January,  1880.  I shall  try  to  show  later  on  that  such  an  assumption  seems  justified, 

; even  without  direct  anatomical  proof.  Still,  I confess  the  case  was  not  entirely 

- convincing,  especially  in  regard  to  the  right  extremity,  which  was  first  affected.  Here 
the  whole  leg  was  in  such  a condition  that  the  obstruction  of  a blood  vessel  could 

t easily  take  place  from  various  causes;  not  so,  however,  on  the  left  leg,  which  had 
previously  been  in  a normal  state.  Certainly  my  attention  was  sufficiently  aroused  to 
keep  me  on  a sharp  lookout  for  similar  cases.  Several  years,  however,  passed  without 
furnishing  further  confirmation  of  my  suspicion.  A number  of  cases  came  under 
my  observation  which,  indeed,  somewhat  resembled  that  of  Mrs.  S.  In  several  in- 
stances I found  the  same  dark-green  sloughs,  firmly  adherent  to  their  base  and  their 
periphery,  occurring  mostly  at  the  malleolar  region  ; sometimes  I could  watch  the 
t separation  of  these  sloughs  and  the  appearance  of  the  deep,  dirty,  sharply  cut  ulcers, 
surrounded,  at  least  at  first,  by  rather  normal  skin,  in  persons  known  to  be,  or  highly 
suspected  of  being,  subjects  of  syphilis.  At  other  times  ulcers  were  seen,  under  simi- 
lar conditions  and  in  the  same  localities,  which  I felt  convinced  had  been  originated  by 
the  separation  of  the  same  escharotic  sloughs.  They  were  generally  of  oval  shape, 
uneven,  very  often  deeper  at  one  side  than  at  the  other,  showing  aflat  semilunar  eleva- 
tion like  the  round  ulcer  of  the  stomach,  with  hard  but  sometimes  inverted  edges, 
furnishing  a thin  watery  secretion  and  either  exhibiting  very  little  tendency  to  extend 
or  to  heal,  or,  after  a very  slow  progress  of  healing,  leaving  a depressed  scar  that  firmly 
adhered  to  the  underlying  tissue,  even  when  not  situated  directly  over  a bone.  Per 
contra,  gummatous  ulcers  as  a rule  show  a great  tendency  to  heal  under  proper  treat- 
ment with  a slightly  depressed,  movable,  and  thin,  parchment-like  scar.  Naturally, 
i such  ulcers  at  first  sight  do  not  differ  much  from  the  common  chronic  ulcer  of  the  leg, 

' especially  if  left  to  themselves  for  some  time,  but  on  close  observation  some  peculiarities 
can  indeed  be  found.  I have  observed  these  so  regularly  in  ulcers  of  the  malleolar 
i region  that  I always  consider  those  as  suspicious  of  syphilis,  and  but  exceptionally  has 

- the  suspicion  failed  of  confirmation  by  the  absence  of  a history  or  other  manifestations 
of  syphilis.  All  such  cases,  however,  which  I have  seen,  unfortunately  belonged  to 
dispensary  practice,  so  that  I was  not  able  to  trace  their  history  and  development  with 

i sufficient  accuracy.  One  case,  however,  occurring  in  private  practice,  offered  a better 

■ opportunity. 

Mrs.  B.,  then  about  fifty  years  of  age,  had  contracted  syphilis  in  August,  1880. 
Although  rationally  treated  from  the  start  by  her  physician,  the  disease  soon  developed 

■ a very  malignant  character,  partly  in  consequence  of  irregularity  of  treatment  owing  to 
the  miserable  state  of  the  patient’s  digestion,  partly  of  constant  family  trouble  and 
excitement.  I first  saw  her  about  a year  after  the  infection,  when  she  presented  super- 

1 ficial  ulcerations  of  the  forehead,  scars  of  ulcers  on  the  legs,  and  gummata  of  the  thighs 
and  arms,  and  ever  since  have  had  her  under  observation.  During  these  six  years  Mrs. 

( B.  hardly  ever  has  been  entirely  free  from  symptoms  of  syphilis,  consisting  mostly  of 
ulcers  of  different  parts  of  the  body.  In  March,  1884,  two  gummata  of  the  size  of  a 

■ small  walnut  made  their  appearance  on  the  lower  third  of  the  right  leg,  breaking  down 
I in  the  nsual  way  and  leaving  two  deep  ulcers  in  an  area  of  considerably  infiltrated  and 
i congested  skin.  These  ulcers,  after  various  periods  of  improvement  and  aggravation, 

; presented  about  the  end  of  June  a clean  granulating  surface,  giving  promise  of  a speedy 
i healing.  Early  in  September  I found  these  ulcers  healed  with  a smooth,  thin,  scar ; 

' the  leg,  which  had  repeatedly  shown  different  degrees  of  oedema,  was  of  natural  size, 

but  below  the  malleolus  internus  two  dark-green,  firmly  adherent  sloughs,  about  the 


176 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


size  and  shape  of  peach  stones,  were  visible,  separated  by  a band  of  slightly  oedematous 
skin  and  causing  no  particular  inconvenience.  Four  weeks  later  the  sloughs  had  come 
off,  leaving  tolerably  clean,  shallow  defects,  with  sharply  cut,  uninfiltrated  edges. 
These  two  ulcers  have  never  entirely  healed  since  ; they  have  not  materially  increased 
in  size,  but  have  been  constantly  changing  in  depth.  At  one  time  in  January,  1885, 
the  greater  part  of  them  had  been  transformed  into  a depressed  adherent  scar,  showing 
several  transverse,  ridge-like  elevations  and  causing  then  considerable  pain,  but  since 
that  time  the  ulcers  have  increased  in  depth  again  and  do  not  undergo  much  change, 
neither  healing  nor  extending,  although  the  patient  is  keeping  very  quiet  and  is  not 
obliged  to  use  her  legs  much. 

So  far  my  own  experience.  In  literature  not  much  is  to  be  found.  Some  of  the 
features  of  syphilitic  ulcers  in  the  chronic  state  are  found  described  in  the  handbooks, 
for  instance,  by  Bumstead  and  Taylor,*  where  the  chronic  swelling  resembling  elephan- 
tiasis Arabum,  as  in  my  first  case,  is  especially  mentioned,  but  the  original  formation 
of  a slough  without  previous  gummatous  infiltration  I have  not  found  distinctly  recog- 
nized. Some  of  the  malignant  precocious  syphilides,  described  originally  by  French 
authors,  often  rapidly  lead  to  sloughing,  but  never  without  a neoplasm  being  previously 
visible,  differing  from  my  cases  by  their  early  appearance.  We  find  the  closest  resemb- 
lance to  spontaneous  gangrene,  however,  in  a description  recently  given  by  Fournierf 
of  what  he  calls  gangrene  primitive,  and  to  which,  he  says,  Bazin  has  given  the  name  of 
tuberculo-gangrenous  syphilide.  I have  tried  to  find  the  original  of  Bazin,  which  Four- 
nier has  not  indicated,  but  have  not  succeeded,  so  that  I cite  the  latter  author: — 

“Here  the  tuberculous  infiltration,  as  soon  as  it  has  been  formed,  takes  a livid  color 
in  the  centre  and  a chocolate  color  in  the  peripheral  portions,  with  insensibility  of  the 
diseased  part ; for  in  reality  the  formation  of  an  eschar  takes  place  under  which  the 
mortified,  insensible,  sloughy  tissues  are  found,  no  external  occasional  cause  being 
recognizable.  The  mortified  parts  take  on  the  appearance  of  gangrene,  they  become 
detached,  and  underneath  the  syphilitic  ulcer  is  found  at  last.  The  symptoms  perfectly 
bear  the  character  of  spontaneous  primary  gangrene.” 

Here  you  have  an  exact  description  of  what  I have  stated  to  have  observed,  only 
that  Bazin  insists  on  the  previous  formation  of  a neoplasm  that  begins  to  disintegrate 
as  soon  as  it  is  formed.  It  is  true,  the  syphilitic  newly  formed  tissue  is  perhaps  the 
most  short  lived,  but  not  so  ephemeral  as  Bazin’s  description  would  lead  us  to  believe; 
only  in  phagedenism  do  we  meet  with  so  rapid  a decay,  yet  Bazin  does  not  identify  his 
tuberculo-gangrenous  syphilide  with  phagedenism.  Has  this  new  formation  not  been 
assumed  perhaps  in  conformity  with  the  usual  experience  that  syphilitic  ulcers  always 
result  from  the  disintegration  of  a specific  product?  And  has  not  the  bona  fide  accept- 
ance of  such  a new  formation  been  the  cause  that  the  gangrenous  ulcer  has  never  been 
distinguished  from  the  gummatous  one?  It  seems  to  me  that  it  is  not  necessary  to 
resort  to  such  an  explanation;  the  sudden  occlusion  of  a small  terminal  branch  of  an 
artery  would  more  satisfactorily  account  for  the  almost  instantaneous  appearance  of 
such  a spontaneous  gangrene.  It  has  been  satisfactorily  shown  that  in  every  stage  of 
syphilis  its  virus  exerts  its  action  most  constantly  on  and  around  the  blood  vessels.  To 
changes  in  the  blood  vessels,  therefore,  particularly  to  endarteritis  obliterans,  we  must 
look  for  an  explanation,  if  we  can  exclude  other  external  or  internal  causes  of  gangrene. 
Endarteritis  in  syphilitic  persons  is  an  established  fact;  it  does  not  detract  from  its 
importance  that  this  arteritis  is  really  not  a specifically  syphilitic  process;  that  it  owes 
its  origin  to  syphilis  in  a great  many  cases  is  generally  conceded.  Such  an  origin 
would  at  the  same  time  explain  the  inefficiency  of  anti-syphilitic  treatment  in  such 


*•  Bumstead  and  Taylor,  “Venereal  Diseases,”  fifth  od.,  p.  60 L. 
f “Gaz.  d.  hopitaux,”  1SS7,  Nos.  37  and  40. 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGRAPHY.  177 


cases.  The  product  of  endarteritis  of  the*  skin  will  no  more  bo  influenced  by  the  same 
than  the  nerve  or  ganglion  that  was  destroyed  by  cerebral  hemorrhage  due  to  specific 
endarteritis.  The  mischief  is  done  by  syphilis,  but  its  result  ceases  to  be  syphilis. 
Laug,  who,  iu  his  lectures  on  the  pathology  and  treatment  of  syphilis,*  has  devoted  an 
entire  lecture  to  the  syphilitic  affections  of  the  circulatory  system,  has  paid  more  atten- 
tion to  this  question  than  oilier  authors.  He  speaks  first  of  arteritis  of  the  larger  blood 
vessels,  leading  in  some  cases  to  gangrene  of  entire  extremities  or  portions  thereof. 
Besides  an  observation  of  his  own,  he  cites  cases  of  Zeissl  and  Lomikowsky,  to  which 
others  of  Nicoladoui,f  Billroth, J Podres?  (cited  by  Bumstead  and  Taylor),  and  Cabot 
and  Warreu||  might  be  added.  The  latter  report  gangrene  of  the  two  lower  thirds  of 
the  right  leg,  and  a gangrenous  spot  three  to  four  inches  in  diameter  on  the  inner  side 
of  the  right  thigh.  I observed  the  following  case  of  endarteritis  of  the  popliteal  artery 
or  one  of  its  branches,  which,  like  Lang’s  case,  took  a favorable  course  under  the  specific 
treatment. 

Mr.  R.,  who  had  contracted  syphilis  in  1874,  consulted  me  in  June,  1882,  for  a 
thickening  of  the  epidermis  between  the  toes  and  on  the  sole  of  the  left  foot.  On 
August  16th  this  thickened  epidermis  was  found  to  be  detached,  covering  a superficial, 
irregularly-shaped,  serpiginous  ulcer,  which,  under  local  applications  and  mixed  treat- 
ment, had  healed  about  September  3d.  After  continued  treatment,  on  October  13th 
the  sole  appeared  smooth,  but  for  several  small  scaling  spots  beneath  the  first  phalanges 
of  the  toes,  but  the  whole  leg,  which  had  been  slightly  cedematous  before,  appeared 
considerably  swollen  from  the  knee  downward  to  the  toes;  the  skin  was  pale,  cool  to 
the  touch,  and  not  sensitive  on  pressure  except  at  the  lower  part  of  the  tibia.  Under 
the  use  of  iodide  of  sodium  within  the  next  few  days  the  swelling  somewhat  subsided;  on 
removal,  however,  of  the  scales  from  the  sole,  ulcers  were  again  found.  On  October 
19th  the  treatment  was  changed  to  hypodermic  injections  of  a one  per  cent,  solution  of 
the  bi-cyanide  of  mercury,  and  soon  the  swelling  began  to  diminish  steadily;  on  the 
25th  the  toes  were  smaller,  and  on  the  28th,  when  nine  injections  had  been  adminis- 
tered, the  ulcers  of  the  sole  had  healed,  the  fourth  and  fifth  toes  were  of  normal  size, 
while  the  second  and  third  and  the  inner  half  of  the  great  toe  were  still  enlarged,  and  on 
the  sole  the  interdigital  spaces  between  the  first,  second  and  third  toes  were  nearly 
obliterated  by  a pad-like  protuberance  of  the  soft  parts.  The  dorsal  aspect  of  the  foot 
still  showed  moderate  swelling  over  the  tibio-tarsal  joint  ; on  the  leg  the  outlines  of  the 
tibia  were  still  concealed  by  oedema  of  the  soft  parts,  which,  on  both  sides  of  the  bone, 
gave  a peculiar  elastic  sensation;  the  front  aspect  of  the  tibia  seemed  to  be  thickened 
by  periosteal  new  formation,  but  was  not  sensitive.  On  November  13th  the  swelling 
had  still  more  subsided,  but,  owing  to  my  protracted  sickness,  I did  not  see  the  patient 
again  until  the  following  May,  when  the  leg  was  in  perfectly  normal  condition,  except 
slight  periosteal  thickening  of  the  upper  and  lower  third  of  the  tibia.  The  extremity 
at  all  times  had  been  cool,  pale  and  almost  free  from  pain;  at  no  time  could  I detect  a 
thickened,  hard  or  enlarged  blood  vessel,  like  in  Lang’s  case,  still  I cannot  think  of 
another  cause  for  the  apparent  obstruction  of  the  circulation  but  of  endarteritis  oblit- 
erans. 

To  return  to  Lang,  he  then  proceeds  to  the  consideration  of  the  affections  of  the 
medium-sized  and  small  arteries,  dwelling  particularly  on  the  importance  of  the  endar- 
teritis of  the  smaller  cerebral  vessels,  which  was  first  studied  by  Heubner  and  con- 
firmed by  other  authors;  Birch-Hirschfeld’s  and  Scliuetz’s  observations  of  endarteritis 
in  hereditary  syphilis,  and  Huber’s  of  calcification  of  blood  vessels  are  then  men- 


* Wiesbaden,  1884-’86.  J Wiener  med.  Woch.,  1879,  No.  51. 

f Wiener  med.  Wochenachrift,  18S1,  p.  231,  No.  8.  £ Centralblatt  f.  Ghirurgie,  1876,  No.  33. 

i|  Ronton  Med.  Journal,  1880,  II,  No.  7. 


Vol.  IV— 12 


178 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


tioned.  I here  wish  to  call  your  attention  to  the  publication  of  Galliard  * on  the  occur- 
rence in  syphilitic  persons  of  the  round  ulcer  of  the  stomach,  to  the  similarity  of  which 
with  the  gangrenous  ulcers  of  the  skin  I have  repeatedly  alluded,  and  on  the  pro- 
bable connection  of  the  same  with  endarteritis. 

Lang  then  continues: — | 

“ Naturally,  the  symptoms  which  follow  an  affection  of  the  blood  vessels  will  vary 
a good  deal  according  to  the  nature  and  extent  of  the  pathological  process,  to  the  size  of 
the  affected  vessel,  and  in  smaller  ones  according  to  the  dignity  of  the  organ  the  vascu- 
lar supply  of  which  is  the  seat  of  the  affection.  Either  dilatation  or  narrowing  and 
obliteration  may  result;  therefore,  we  must  expect  in  due  time  either  an  aneurism  or 
such  phenomena  as  usually  follow  obliteration  of  blood  vessels.  The  constringing  and 
obliterating  arteritis  will  be  the  less  pronounced  the  smaller  the  area  supplied  by  the 
affected  vessel,  the  less  important  its  physiological  function,  and  the  more  favorable  the 
circumstances  for  the  establishment  of  a collateral  circulation,  which,  in  the  slow  devel- 
opment of  the  arteritis,  may  be  effected  with  hardly  any  disturbance.  But  if  terminal 
or  a larger  number  of  blood  vessels  are  the  seat  of  the  affection,  an  insufficient  or 
entirely  interrupted  circulation  and  consequent  diminished  nutrition  and  necrobiosis 
are  inevitable.  Death  of  the  foetus  in  consequence  of  affections  of  the  umbilical  or 
placental  vessels,  circumscribed  softening  of  the  brain  or  of  the  heart,  ulcerations  of 
skin  and  of  the  mucous  membranes,  have  to  be  looked  for  as  the  natural  consequences 
of  arteritis.” 

The  probability  that  arteritis  may  begin  in  small  peripheral  vessels  and  spread  to 
larger  trunks  has  been  distinctly  insisted  upon  by  Jonathan  Hutchinson  in  a paper 
published  in  1884,J  which  seems  to  have  escaped  Lang;  its  title  is,  “A  Case  of  Syphilis 
in  which  the  Fingers  of  One  Hand  became  Cold  and  Livid — Suspected  Arteritis.” 

The  case  had  been  under  Hutchinson’s  observation  twenty  years  ago,  but  had  not 
been  published  because  no  satisfactory  conjecture  as  regards  diagnosis  could  then  be 
offered.  “ Only  in  reading  over  the  notes  again,  it  occurred  to  me,”  Hutchinson  says, 
‘ ‘ that  the  cause  of  the  symptoms  must  have  been  inflammatory  occlusion  of  the  arter- 
ies of  the  hand.  Lividity,  coldness  and  pain  were  indicative  rather  of  disturbance  of 
nutrition  and  circulation  than  of  nervous  influence.  It  will  be  seen,”  further  on  Mr. 
Hutchinson  says,  “that,  although  the  finger-tips  never  actually  went  into  gangrene, 
they  were  very  near  it.  Since  this  occurrence  I have  seen  several  cases  favoring  the 
belief  that  arteritis  may  begin  in  the  small  peripheral  vessels  and  may  travel  to  large 
trunks.” 

I am  well  aware  that  it  will  require  the  anatomical  proof  that  changes  in  an  artery 
leading  to  a gangrenous  portion  of  the  skin  must  actually  be  shown  to  exist  to  estab- 
lish as  an  irrefutable  fact  what  I have  maintained.  This,  I confess,  I have  not  been 
able  to  do  thus  far,  nor  can  I hope  to  find  the  opportunity  myself  in  the  future.  To 
awaken  the  interest  of  the  profession  in  such  an  investigation,  I have  taken  leave  to 
bring  my  observations  before  this  assembly  and  to  submit  to  your  present  and  future 
consideration  the  following  conclusions: — 

1.  Ulcers  resembling  the  so-called  gummatous  syphilitic  ulcer  may  occasionally 
result  from  circumscribed  spontaneous  gangrene  of  the  skin  without  the  previous  forma- 
tion of  a syphilitic  neoplasm. 

2.  Such  ulcers  may  be  distinguished  by  several  peculiarities  in  shape,  formation  of 
the  floor  and  course. 


* “ Archives  g6n6rales  de  medeeine,”  janvier,  1886.  “Syphilis  gastriquc  et  ulcere  simple  de 
l’estomac.” 

j"  Loc.  cit.,  p.  305. 


J Med.  Times  and  Gazette,  1884,  i,  p.  374. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


179 


3.  They  are  not  at  all  or  but  very  little  affected  by  anti-syphilitic  treatment. 

4.  The  spontaneous  gangrene  in  such  cases  is  probably  due  to  endarteritis  obliterans. 


DISCUSSION. 

Dr.  Unna  remarked  that  if  endarteritis  obliterans  lias  any  causal  relationship  to 
necrosis,  the  frequency  of  extreme  endarteritis  in  the  initial  lesion  and  the  rarity  of 
necrosis  there  is  remarkable.  It  is  very  apparent  that  other  factors,  such  as  a local 
absence  of  anastomoses,  hemorrhages,  traumata,  pressure,  etc. , must  also  be  present 
before  cutaneous  necrosis  can  occur. 

Dr.  Zeisler,  of  Chicago,  mentioned  a case  of  chronic  ulceration  of  the  lower  leg 
in  a man,  for  which  no  other  cause  could  be  found  but  that  the  patient  had  violently 
struck  his  leg  below  the  knee  about  a year  ago.  The  ulceration  was  veiy  obstinate 
to  treatment,  and  finally  yielded  to  mercurial  plaster  and  the  internal  use  of  iodide  of 
potassium.  Soon  new  ulcerations  appeared,  of  decidedly  kidney-shape,  and  close 
inquiry  revealed  the  fact  that  the  patient  had  contracted  syphilis  about  ten  years  ago. 
As  in  this  case  no  gumma  preceded  the  formation  of  the  ulcers,  it  seems  to  belong 
to  the  class  described  by  Dr.  Klotz. 


ISO 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


SECOND  DAY. 


STUDIES  IN  HIRSUTIES, 

ETUDES  SUR  L’HIRSUTIE. 

STUDIEN  UBER  DIE  HIRSUTIES. 

BY  GEORGE  H.  ROHE,  M.D., 
Baltimore,  Md. 


The  generally  hairless  condition  of  the  human  body  is  ascribed  by  Mr.  Darwin  to 
the  influence  of  sexual  selection.  The  great  naturalist  recognized  the  inadequacy  of 
the  principle  of  natural  selection  to  account  for  this  variation  from  the  probable  primi- 
tive type.  Mr.  Alfred  Russell  Wallace  likewise  points  out  the  improbability  of  natural 
selection  having  produced  the  disappearance  of  the  hairy  coating  from  the  skin  of  man ; 
but  as  this  observer  fails  to  accept  the  Darwinian  hypothesis  of  sexual  selection,  he 
infers  the  influence  of  “some  other  power  than  the  law  of  the  survival  of  the  fittest,” 
to  account  for  this  phenomenon.  This  “other  power  ” of  Mr.  Wallace  is  “a  superior 
intelligence  which  has  guided  the  development  of  man  in  a definite  direction  and  for 
a special  purpose.”*  Mr.  Joseph  J.  Murphy,  in  his  profound  essay  on  “Habit  and 
Intelligence,”  takes  substantially  the  same  view  as  Mr.  Wallace.  On  the  other  hand, 
Mr.  Grant  Allen,  a writer  of  some  note  on  subjects  in  the  domain  of  natural  science, 
maintains,  with  some  plausibility,  that  the  modification  was  begun  under  the  influ- 
ence of  natural  selection,  and,  as  a secondary  sexual  character,  completed  by  sexual 
selection.! 

It  is  not  proposed  in  this  paper  to  give  further  consideration  to  this  question.  Atten- 
tion is  merely  directed  to  it  as  having  an  incidental  bearing  upon  the  problem  to  be 
discussed.  . ' 

The  occurrence  of  generalized  hirsuties  in  human  beings  is  considered  by  Darwin  as 
a reversion  to  the  type  of  the  hairy  ancestors  of  the  race,  and  Unna  lias  very  cleverly 
suggested  that  universal  hirsuties  is  merely  an  arrest  of  development.  It  is  known,  for 
example,  that  the  foetus,  during  the  pre-natal  life  becomes  thickly  covered  with  hair, 
which  usually  falls  out  before  birth,  but  which  sometimes  remains  until  after  the  child 
is  several  weeks  old.  The  new  growth  of  hair  is,  according  to  Unna — who  has  so 
greatly  advanced  our  knowledge  of  this  subject — of  a totally  different  type.  In  hyper- 
trichosis, then,  according  to  this  observer,  this  change  of  type  in  the  growth  of  the  hair  • 
does  not  take  place,  and  hence  the  primitive  or  ante-natal  type  becomes  permanent. 

Neither  of  these  theories  seems  to  the  present  writer  sufficiently  well  established 
to  explain  the  occurrence  of  the  deformity  under  discussion,  and  it  has  seemed  to  him 
excusable  to  attempt  the  further  elucidation  of  the  problem  of  hirsut  ies  as  it  presents  itself 
to  the  consideration  of  the  anthropologist,  the  physician  or  the  dermatological  specialist. 


* “On  Natural  Selection,”  page  359. 

| “A  Problem  in  Human  Evolution.”  Fortnightly  Review,  1ST9. 


SECTIONT  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


1S1 


Hirsuties,  or  hypertrichosis,  is  an  abnormal  condition,  manifested  by  excessive 
growth,  abnormal  distribution  or  heterochronic  development  of  hair.  Inasmuch  as 
there  is  no  generally  accepted  standard  of  hairiness,  the  terms  used  to  describe  the 
condition  are  merely  relative.  What  is  considered  excessive  hairiness  in  one  race,  or 
individual  or  class  of  individuals,  may  be  thought  normal  in  others.  For  example,  the 
Hebrew  race  has,  as  a rule,  an  abundant  pilous  development  upon  the  surfaces  usually 
covered  with  hair,  but  in  ordinary  cases  this  would  not  be  called  hypertrichosis.  The 
degree  of  hairiness  which  may  be  considered  normal  varies  within  pretty  wide  limits, 
principally  because,  in  the  male  sex,  moderate  examples  of  hypertrichosis  have  not 
attracted  much  attention. 

To  the  dermatologist,  hypertrichosis  is  of  interest,  especially  as  it  occurs  upon  the 
face  in  the  female  sex.  Through  the  fertilizing  suggestion  of  Michel,  of  St.  Louis, 
developed  by  Hardaway,  Fox  and  others,  in  this  country,  a sovereign  remedy  is  at  our 
command  in  the  electrolytic  current,  but  our  knowledge  of  the  aetiology  of  the  condi- 
tion is  still  vague  and  indefinite. 

If  one  studies  the  literature  of  this  subject  and  makes  good  use  of  his  opportunities 
to  examine  cases  of  hypertrichosis,  it  soon  becomes  apparent  that  the  differences  between 
so-called  universal  hirsuties  and  local  hypertrichosis  are  only  of  degree,  and  that  prob- 
ably the  causes  of  the  one  will  also  account  for  the  other. 

Readers  of  the  Old  Testament  Scriptures  are  familiar  with  the  marked  case  of  uni- 
versal hirsuties  described  in  the  twenty-fifth  chapter  of  Genesis.  ‘ ‘ As  hairy  as  Esau  ’ ’ 
has  passed  into  a proverb,  and  the  description  given  of  this  son  of  Isaac  is  sufficiently 
detailed  to  indicate  that  it  was  intended  to  represent  an  abnormally  hairy  individual. 
This  is  evident  from  the  character  of  the  disguise  by  which  Jacob  was  enabled  to 
defraud  his  twin  brother  out  of  his  father’s  blessing.  It  seems  somewhat  surprising 
that  no  mention  is  made  in  the  Scriptures  of  any  abnormality  in  hirsute  development 
among  Esau’s  descendants. 

In  modem  literature  several  remarkable  cases  of  universal  hirsuties  are  recorded. 
Among  the  earliest  of  these  is  Barbara  Ursler,  of  whom  contemporary  chroniclers  give 
a good  account.  She  lived  in  the  seventeenth  century  and  was  exhibited  in  various 
European  cities.  Nothing  is  known  of  her  family  history,  and  the  bizarre  explanations 
given  by  the  older  authors  to  account  for  the  abnormal  hairiness  are  not  profitable  mat- 
ters for  discussion  at  the  present  day. 

The  first  instance  of  hirsuties  running  through  several  generations  of  which  we  have 
any  account  is  that  of  the  Amras  or  Ambriz  family,  from  the  west  coast  of  Africa.  It 
is  recorded  by  Aldrovandus  in  his  “Monstrorum  Historia.  ” * The  family  consisted  of 
a father  aged  forty,  a son  aged  twenty,  and  two  daughters  of  eight  and  twelve  years 
respectively.  In  the  hairy  family  of  Burmah,  first  described  by  Crawford,  the  hirsuties 
has  run  through  three  generations.  The  grandfather  was  presented  to  the  King  of 
Burmah  at  the  age  of  five,  having  been  brought  from  Laos.  This  individual,  Schwe- 
maong  (or  Scheve-mwong),  was  of  the  average  height  of  the  Burmese  and  of  a delicate 
constitution.  Barring  his  excessive  hairiness  and  defective  teeth,  he  presented  no 
abnormality.  Crawford  saw  him  for  the  first  time  in  1829,  when  he  was  thirty  years 
old.  Schwe-maong  asserted  that  none  of  his  ancestors  were  hairy,  but  as  he  was  only 
five  years  old  at  the  time  of  his  capture,  his  evidence  upon  this  point  is  not  very  trust- 
worthy. 

At  the  age  of  twenty-two,  Schwe-maong  was  married  by  the  King  to  a Burmese 
woman,  who  bore  him  four  daughters.  Two  of  these  died  in  infancy,  showing  nothing 
abnormal.  Of  the  remaining  two,  the  elder  was  normal  at  the  age  of  five,  after  which 
age  nothing  further  could  be  learned  of  her.  The  other  child,  Maphoon,  began  to 


* Opera,  Yol.  II. 


182 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


develop  an  excessive  hairy  growth  at  the  age  of  six  months,  and  became  entirely  cov- 
ered Math  hair. 

Maphoon  was  married  (although,  according  to  Darwin,  the  king  was  compelled  to 
bribe  a man  to  marry  her),  and  had  two  sons,  to  both  of  whom  she  transmitted  her 
abnormality.  One  of  these  sons  died  some  years  since,  but  the  other,  Moung  Phoset  is 
living,  and  was  on  exhibition  with  Maphoon  last  year,  in  London. 

The  case  of  Adrian  Jeftichjew,  of  Kostroma,  in  Russia,  is  also  a remarkable  one. 
He  was  “discovered  ” about  1870,  and  exhibited  in  various  cities  of  Europe,  where  he 
attracted  much  attention,  and  was  examined  by  a number  of  scientists,  among  whom 
was  Prof.  Virchow,  who  made  him  the  subject  of  a lecture  before  one  of  the  Berlin 
medical  societies.  Neither  the  reputed  father  nor  the  mother  of  Adrian  are  known  to 
have  been  similarly  affected.  Inquiries  have  elicited  the  fact,  however,  that  he  was 
born  during  his  father’s  absence  in  military  service,  and  that  in  a neighboring  district 
lived  a woman  who  had  a very  long  beard.  The  inference  is  that  a hairy  family  was 
known  to  exist  near  the  Kostroma  district  at  the  time  of  Adrian’s  birth,  and  that  some 
member  of  this  family  performed  some  of  the  duties  of  husband  to  Adrian’s  mother 
during  the  absence  of  her  legitimate  spouse  in  the  army. 

Adrian  had  several  children,  to  one  of  whom,  Fedor,  he  transmitted  his  deformity. 
This  son  has  been  extensively  exhibited  as  “the  Russian  dog-faced  boy”  in  this 
country  during  the  last  few  years. 

The  remarkable  case  of  the  Mexican  dancer,  Julia  Pastrana,  belongs  to  this  class. 
Her  appearance  was  exceedingly  repulsive,  but  she  must  have  possessed  some  charms  or 
powers  of  fascination,  for  she  died  giving  birth  to  a child.  This  child  developed 
hirsuties  a few  months  after  birth.  No  trace  of  its  further  history  could  be  obtained. 

A few  years  since,  a young  girl  completely  covered  with  hair  was  exhibited  in 
London  as  “ Krao,  the  missing  link.”  She  was  found  in  the  interior  of  Laos,  whence  it 
will  be  remembered  Schwe-maong  is  also  reported  to  have  come.  Krao’s  parents  are 
said  to  have  been  hairy  people.  This  is  a point  of  great  interest,  as  it  seems  to  indicate 
the  existence  of  a large  family,  or  possibly  tribe,  of  hairy  people  in  farther  India. 

Two  instances  of  moderate  hirsuties  running  through  three  generations  are  reported 
by  Michelson.  * 

Surgeon  Major  A.  Leith  Adams  gives  a listf  of  nine  recruits  with  “redundance  of 
hair  on  the  body.”  In  six  the  testimony  showed  that  the  abnormality  was  hereditary, 
being  usually  transmitted  in  the  male  line. 

A remarkable  feature  iu  most  of  these  cases  is  the  defective  development  of  the  teeth. 
In  the  Burmese  family,  Schwe-maong  had  four  upper  and  five  lower  teeth.  The  molars 
were  entirely  absent.  The  teeth  were  small,  but  in  good  condition  when  examined,  at 
the  age  of  thirty.  Maphoon,  his  daughter,  has  the  same  anomalous  dentition.  Moung 
Phoset,  the  grandson,  has  four  teeth  in  the  upper  and  six  in  the  lower  jaw. 

Adrian  Jeftichjew  had  only  the  left  upper  canine,  but  all  the  teeth  were  present  in 
the  lower  jaw.  j:  His  sou  Fedor  has  two  upper  canine  and  two  lateral  and  one  middle 
incisor  in  the  lower  jaw.  One  of  these  seems  to  have  been  lost,  as  Fedor  was  reported 
to  have  four  lower  teeth  in  1873. 

According  to  Max  Bartels,  all  the  deciduous  teeth  were  developed  in  Krao,  but  in  a 
photograph  of  this  girl  in  my  possession  the  teeth  seem  very  defective.  Julia  Pastrana, 
on  the  other  hand,  is  said,  by  a Mr.  Preswich,  who  examined  her,  to  have  had  a double 
set  of  teeth  \ in  each  jaw.  A curious  pendant  to  this  anomaly  occurs  in  hairless  dogs, 


* Virchow’s  Archiv,  Bd.  100.  f London  Lancet,  May  16th,  1874,  page  688. 

{ Statement  of  Michelson.  Other  accounts  stato  that  only  four  teeth  developed,  but  traces  of 
others. 

j)  Beigel.  “ Ueber  Abnormo  Behaarung  beim  Menschen.”  Virchow’s  Archiv,  Bd.  44,  page  427. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


183 


as  pointed  out  by  Mr.  Darwin.  These  animals  are  said  to  always  have  defective 
teeth.* 

The  attempt  to  account  for  the  occurrence  of  hirsuties  by  ascribing  it  to  atavism,  or 
reversion  to  an  ancestral  type,  has  failed  to  explain  it.  In  no  pathological  condition 
has  such  an  atavistic  tendency  been  shown.  The  theory  which  ascribes  it  to  an  arrest 
of  development  (Unna)  is  a very  attractive  and  plausible  one,  but  seems  to  me  not  yet 
sufficiently  established.  In  my  opinion,  the  only  view  that  may  be  safely  accepted  is 
that  the  hirsuties  is  an  hereditary  trait.  It  is  true  the  hairy  character  is  not  always 
transmitted  to  the  descendants,  but  it  must  be  recollected  that  two  factors  enter  into  the 
production  of  offspring,  the  male  and  the  female  element.  The  laws  of  heredity  do 
not  yet  admit  of  a scientific  explanation,  but  the  observations  on  record  show  many 
curious  facts  bearing  upon  this  process. 

The  history  of  cases  of  hirsuties  shows  that  heredity  of  the  abnormality  is  usually 
direct  and  generally  in  the  male  line.  From  the  preeminently  greater  hairiness  of 
males,  this  might  reasonably  be  expected.  The  cases  of  the  Burmese  family,  the 
Ambriz  family,  the  Kostroma  people,  J uiia  Pastrana  and  her  child,  and  Krao,  show 
that  universal  hirsuties  is  nearly  always  hereditary,  and  there  is  good  reason  to  believe 
that  most  cases  of  local  hypertrichosis  may  be  explained  in  the  same  way. 

In  the  cases  of  hypertrichosis  in  females  which  have  come  under  my  notice  during  the 
past  five  years  there  are  three  cases  of  heredity  or  family  tendency  to  the  disease.  Beigel 
and  others  have  noticed  the  same  tendency  to  inheritance  of  a beard  or  moustache. 
Max  Nordau  says,  probably  with  some  exaggeration,  that  the  Provencal  women  gener- 
ally have  beards,  moustaches  and  whiskers.  In  women  of  the  Hebrew  race  facial 
hypertrichosis  is  often  very  marked.  The  bridge  of  hair  connecting  the  eyebrows 
across  the  root  of  the  nose  is  frequently  seen  in  entire  families,  transmitted  from  gen- 
eration to  generation. 

The  apparent  exceptions  to  the  laws  of  heredity  presented  by  hypertrichosis  are 
difficult  to  account  for,  but  not  more  so  than  in  other  malformations  and  diseases.  Thus 
pigmented  nsevi  are  often  hereditary  —they  frequently  run  through  several  generations, 
and  yet  certain  members  of  a “marked  ” family  may  be  entirely  free  from  these  blem- 
ishes. Psoriasis  and  xanthoma  present  similar  peculiarities.  The  difficulty  of  explaining 
these  anomalies  is  owing  to  our  ignorance  of  the  laws  of  heredity.  Recent  embryo- 
logical  researches  seem  to  indicate  that  the  male  and  female  elements  give  rise  to 
different  germinal  layers,  the  epiblast  being  chiefly  derived  from  the  male  element, 
while  the  hypo-  and  mesoblast  are  developed  from  the  female  pro-nucleus.  This,  if 
established,  would  explain  some  of  the  phenomena  of  heredity.  Thus,  abnormalities 
of  epithelial  structures  would  be  more  likely  to  be  transmitted  in  the  male  line,  while 
those  of  the  connective  tissue  and  vascular  structures  would  be  principally  inherited  in 
the  female  line.  The  fact  that  the  hair  on  the  face  of  women  so  often  begins  grow- 
ing at  puberty  or  after  the  menopause  does  not  contradict  the  view  here  expressed,  that 
hypertrichosis  is  a hereditary  abnormality.  Many  hereditary  diseases  or  peculiarities  do 
not  make  their  appearance  until  later  in  life.  The  chief  difficulty  lies  in  explaining  how 
the  parental  influence  is  exercised  in  producing  similar  physical  traits  in  the  offspring. 

While  expressing  the  opinion  that  hirsuties  is,  in  most  cases,  hereditary,  I am  not 
unmindful  of  the  fact  that  the  condition  may  be  acquired.  Certain  neurotic  and  irrita- 
tive conditions  are  recognized  as  favoring  the  development  of  hypertrichosis  in  cases 
where  no  hereditary  tendency  can  be  traced.  The  occurrence  of  facial  hirsuties  in 
insane  women  may  be  looked  upon  as  belonging  to  the  neurotic  variety.  Irritative 
hypertrichosis  is  frequently  seen  by  surgeons  upon  portions  of  the  skin  subjected  to  the 
constant  and  long-continued  action  of  irritants. 


* “ Origin  of  Species,”  page  9. 


184 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


DISCUSSION. 

Dr.  Unna,  of  Hamburg,  regarded  the  paper  as  prudent,  so  far  as  the  patholog- 
ical portion  was  concerned.  He  stated  that  he  upheld  his  theory,  which  he  had  put 
forth  as  a more  scientific  one  than  other  theories  which  had  up  to  that  time  been 
advanced.  He  had  not  been  able  to  study  the  skin  histologically.  This  is  the  only 
way  in  which  advances  can  be  made,  and  he  urged  those  who  have  an  opportunity 
to  make  such  studies.  The  direction  of  hair  development  changes  after  birth,  and  it 
would  be  interesting  to  secure  portions  of  skin  to  examine  for  these  changes  in  the 
different  layers  of  the  skin.  It  is  certainly  an  hereditary  disease,  but  scientifically 
this  is  not  a sufficient  explanation. 

Dr.  Thin  made  some  general  remarks  on  abnormal  hairiness.  He  considered  that 
in  the  perfect  physiological  type  the  hairy  regions  are  sharply  demarkated  from  the 
non-hairy  regions,  and  that  disorderly  growth  of  hair  either  indicated  coarseness  and 
defective  development  of  the  individual  or  deficiency  in  sexual  differentiation.  He 
instanced  the  fact  of  great  hairiness  of  the  limbs,  which  the  vulgar  have  associated 
with  strength,  but  which,  on  the  contrary,  is  associated  with  constitutional  debility. 
This  had  been  first  pointed  out  to  him  by  Paget,  in  consultation  on  a case  of  tuber- 
culosis of  the  testis.  When  examining  the  man  for  evidence  of  scrofulous  taint,  Sir 
James  considered  that  the  great  hairiness  of  the  patient’s  legs  was  evidence  in  that 
direction. 

Sir  James  mentioned  to  Dr.  Thin  that  a recruiting  officer  of  large  experience  in 
England  had  found  that  hairy  recruits  were  less  resistant  to  exposure  and  disease 
than  recruits  whose  limbs  and  bodies  were  not  hairy.  Since  his  attention  had  been 
called  to  this  point  by  Sir  James,  Dr.  Thin  has  had  many  opportunities  of  verifying 
its  accuracy,  and  has  satisfied  himself  that  hairiness  of  the  legs  and  arms,  particularly 
of  the  legs  (he  spoke  of  men  chiefly),  is  a sign  of  constitutional  weakness. 

In  regard  to  the  disorderly  growth  of  hair  as  an  indication  of  deficient  sexual  differ- 
entiation, he  instanced  the  cases  in  which  women  have  more  or  less  moustache  or  hair 
on  the  chin.  Although  the  presence  of  hair  on  the  upper  lip  in  a woman  does  not 
necessarily  coincide  with  sterility,  it  often  does,  and  the  chances  of  a woman  with  a 
moustache  being  fertile  are  not  so  great  as  the  chances  of  a woman  whose  face  is  not 
disfigured  by  hair. 

As  regards  the  growth  of  hair  on  the  chin  more  particularly,  his  experience, 
although  not  sufficiently  large  to  enable  him  to  speak  dogmatically,  had  led  him 
to  consider  it  probable  that  the  power  of  conception  in  a woman  is  possibly  very 
feeble  or  nil  when  strong  hairs  begin  to  develop  on  the  chin.  It  is  notorious  that  in 
many  women  the  growth  of  a formidable  moustache  coincides  with  the  suppression 
of  sexual  activity. 

Dr.  Thin  further  related  a remarkable  case  in  which  a woman,  aged  twenty-nine, 
was  sent  to  him  on  account  of  an  enormous  growth  of  hair  over  the  sternum  and 
round  both  mammae.  She  had  also  some  stout  hairs  on  the  chin.  This  woman  was 
tall  and  somewhat  masculine  in  build,  appearance  and  walk,  as  well  as  voice.  The- 
catamenia  were  regular,  but  lasted  only  about  one  day,  and  were  deficient  in  quantity. 
The  sexual  instincts  must  have  been  present,  as  her  object  in  coming  to  Dr.  Thin  was 
to  get  rid  of  the  hairs  before  marriage.  The  hairs  on  the  sternum  were  black,  thick, 
and  from  a quarter  of  an  inch  to  three-quarters  of  an  inch  long.  The  mammae  were 
rather  larger  than  usual,  natural  in  appearance,  and  the  nipples  and  areolae  fully 
developed.  The  areolae  were  free  from  hairs,  but  the  whole  mammae  were  swathed 
by  a mass  of  black,  thick  hairs,  averaging  from  a quarter  of  an  inch  to  an  inch  and  a 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


185 


half  long,  and  growing  symmetrically  in  a circular  direction.  All  these  hairs  were 
destroyed  successfully  by  electrolysis.  This  woman  stated  that  she  had  a younger 
sister  who  had  had  a large  growth  of  hair  ou  the  mammae.  She  had  married  and 
suckled  her  child,  and  shortly  after  the  secretion  of  milk  was  established  in  the 
mammae  the  hairs  had  fallen  out  and  had  never  returned. 

Dr.  Gottiieil,  of  New  York,  had  removed  upward  of  10,000  hairs  from  the 
face  of  a single  woman,  by  electrolysis.  The  patient  was  a tall  and  robust  Jewess, 
aged  thirty,  and  the  mother  of  two  children.  Four  years  ago,  her  youngest  child 
being  two  years  old,  the  menses  stopped  suddenly  and  entirely.  She  had  always 
been  regular;  and  when,  some  months  later,  it  became  evident  that  she  was  not 
pregnant,  she  was  repeatedly  examined  and  treated  for  her  amcnorrhoea  by  leading 
gynaecologists,  without,  however,  reaching  a diagnosis  or  being  cured.  Coincidently 
with  the  appearance  of  the  amenorrhoea  she  noticed  a sudden  increase  in  the  size 
and  quantity  of  the  hair  upon  her  face,  breast  and  limbs.  For  a time  she  attempted 
to  control  the  growth  by  depilatories  and  the  scissors;  but  it  increased  so  rapidly  that 
her  beard  equaled  that  of  an  ordinary  man.  Hysteria  and  other  nervous  affections 
appeared;  mental  depression  was  very  marked,  and  the  patient  became  a burden  to 
herself  and  her  friends.  Electrolysis  was  used  then  as  a depilatory  measure,  and  she 
eagerly  availed  herself  of  its  help.  When  I first  saw  her,  several  thousand  hairs 
had  already  been  thus  removed.  Her  beard  was  as  thick  as  that  of  a heavily-bearded 
man;  and  the  hairs  were  as  strong  and  coarse  as  we  are  accustomed  to  see  them  in 
very  dark  meu.  For  three  years  electrolysis  was  persistently  used,  and  over  11,000 
hairs  removed.  In  spite  of  most  careful  procedure  many  returned,  and  the  stimula- 
tion of  the  electric  current  seemed  to  incite  the  lanugo  hairs  to  constantly  increasing 
growth.  At  last  it  was  gotten  under  control;  but  as  the  destruction  of  each  hair 
papilla  involved  necessarily  the  destruction  of  a certain  amount  of  the  surrounding 
tissues,  the  loss  of  substance  was  very  considerable.  The  entire  bearded  area  was 
depressed  below  the  level  of  the  skin  of  the  rest  of  the  face  ; but  the  cicatrix  was 
diffused  and  very  superficial,  and  the  patient  was  well  pleased  with  the  result.  A 
few  hairs  yet  remained,  and  for  these  I treated  her  from  time  to  time.  Early  this 
year,  without  any  cause,  and  without  any  change  in  any  other  way,  her  courses  re- 
appeared, and  have  since  been  normal.  Soon  afterward  she  noticed  that  the  long, 
dark  hairs  were  disappearing  from  her  limbs  aud  chest,  and  no  more  dark  hairs 
appeared  upon  her  face.  To-day  she  is  hardly  more  hairy  than  brunettes  of  her 
type  usually  are. 

Dr.  Ravogli,  of  Cincinnati,  O.,  said  that  the  human  race  could  be  divided  into 
classes  by  the  nature  of  their  hair.  He  had  noticed  that  men  have  a greater  devel- 
opment of  hair  upon  the  face  and  about  the  ears  and  nostrils  at  about  the  age  of 
forty-five  than  in  earlier  life,  and  he  believed  that  up  to  this  time,  or  until  the  skele- 
ton was  perfectly  formed,  the  calcareous  salts  were  taken  up  by  the  bones,  and  after 
this  period  were  appropriated  by  the  hairy  growth.  If  hair  be  burned,  we%find  salts 
of  lime  in  the  ash,  and  he  thinks  there  is  a relation  between  the  quantity  of  calcare- 
ous salts  and  abnormal  growth  of  hair. 

Dr.  Henry  J.  Reynolds,  of  Chicago,  111. , said  the  aetiology  of  hirsuties  was  a 
very  intricate  question,  and  one  in  which  it  was  almost  impossible  to  arrive  at  any- 
thing definite.  The  question  had  already  been  very  thoroughly  discussed  by  those 
who  had  preceded  him,  but  after  all,  it  was  only  an  exchange  and  interchange  of 
opinion  regarding  the  subject.  He  believed,  however,  that  there  should  be  two 
forms  of  hirsuties  recognized,  viz.,  the  hereditary  and  that  which  is  acquired  during 


186 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


the  life  of  the  individual.  It  was  a generally  conceded  fact  that  in  the  hereditary  or 
congenital  form  there  was  a deficiency  in  the  development  of  the  teeth,  notwithstand- 
ing the  fact  that  in  the  veiy  interesting  case  of  Krao,  referred  to  by  the  essayist, 
which  Dr.  Reynolds  had  had  the  opportunity  of  examining,  the  teeth  were  well 
formed. 

In  the  acquired  form,  which  was  almost  always  met  with  in  the  female,  it  was 
his  observation,  or  rather  his  opinion,  whether  that  was  based  upon  intelligent  obser- 
vation or  not,  that  the  condition  depended,  in  many  cases,  upon  sexual  or  menstrual 
disorder.  He  thought  there  was  a connection  between  the  two,  very  much  as  there 
is  between  acne  and  disorder  of  the  sexual  functions. 

Dr.  Rohe,  in  closing,  said  there  were  some  cases  not  explicable  on  the  theory  of 
heredity,  and  he  could  not  explain  such  cases  as  that  mentioned  by  Dr.  Gottheil. 
The  statement  made  by  Dr.  Thin,  that  excessive  hair  upon  the  body  should  be 
regarded  as  a sign  of  weakness,  was  new  to  him,  and  he  was  inclined  to  believe  in 
the  popular  idea  that  the  man  with  plenty  of  hair  upon  the  body  was  usually  a 
strong  man. 


ON  A NEW  METHOD  OF  TREATING  SKIN  DISEASES  LOCALLY. 

NOUVELLE  METHODE  DE  TRAITEMENT  LOCAL  POUR  LES  MALADIES  DE  PEAU. 
UBER  EINE  NEUE  METHODE  IN  DER  LOKALEN  BEHANDLUNG  DER  HAUTKRANKHEITEN 

BY  DR.  H.  VALENTINE  KNAGGS, 

London,  England. 

For  more  than  two  years  I have  used  the  local  applications  to  which  I am  about  to 
refer  in  the  treatment  of  skin  diseases,  and  have  obtained  results  which  have  far  exceeded 
my  original  expectations,  especially  in  such  cases  as  are  accompanied  by  a weeping  surface, 
or  are  of  an  inflammatory  or  irritable  character,  as  in  the  various  forms  of  eczema  and 
other  non-specific  exudations. 

The  introduction  of  lanolin  will,  in  many  respects,  help  to  pave  the  way  for  the 
introduction  of  these  remedies,  since  one  of  the  attributes  of  this  peculiar  fat,  to  which 
considerable  attention  has  of  late  been  directed,  is  its  remarkable  power,  within  certain 
limits,  of  absorbing  and  mixing  with  water.  Indeed,  the  extreme  utility  of  the  addition 
of  water  and  medicated  watery  fluids  to  ointments  is  daily  becoming  more  fully 
recognized. 

The  inunction  of  the  body  with  fixed  oils  has  been  proved,  by  numerous  independent 
observers,  to  be  of  immense  service  in  febrile  and  other  diseases,  especially  in  children. 
When  so  applied  it  has  been  found  that  glycerine  fats,  and,  to  a less  extent  mineral 
fats,  greatly  promote  skin  action,  and  even  in  some  cases  excite  inflammatory  action 
and  produce  eruptions,  by  causing  an  increased  flow  of  blood  to  the  skin.  As  a conse- 
quence, the  blood  is  temporarily  withdrawn  from  the  deep-seated  structures  of  the  bod}' 
and  a high  temperature  often  becomes  rapidly  lowered.  Inunction  also,  in  some 
measure,  protects  the  surface  from  atmospheric  changes,  and  nutrition  is  promoted  by 
the  diminished  tissue  changes  that  take  place,  as  well  as  by  a limited  amount  of 
absorption.  When  applied  to  small  areas  of  the  surface,  especially  such  as  are  affected 
by  disease,  skin  action  would,  if  it  is  possible  to  reason  by  analogy,  be  similarly  increased, 
with  consequent  augmentation  of  inflammation. 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGRAPII Y. 


187 


Fixed  oils,  with  perhaps  the  single  exception  of  lanolin,  can  no  more  he  termed 
adhesive,  in  the  strict  sense  of  that  word,  than  water  or  watery  solutions  can  be.  What- 
ever their  consistence  may  he,  their  use  undoubtedly  entails  greater  functional  activity 
of  the  skin,  with  an  accompanying  increase  either  of  perspiration  or  of  discharge,  the 
exit  of  which  is  not  impeded,  because  the  particles  of  oil  and  water,  when  brought  into 
contact,  serve  to  repel  one  another.  A layer  of  any  oily  substance  applied  to  the  skin 
is  but  slightly  attached  to  the  surface,  and  is,  therefore,  easily  raised,  exuding  fluids 
will  be  able  to  escape  readily,  and  will  pass  directly  through  this  layer  when  a fluid  oil 
is  used,  and  when  the  fat  is  of  a solid  character  the  secretions  will  travel  along  its  under 
surface  until  a suitable  outlet  presents  itself. 

In  order  to  render  oily  substances  adhesive,  there  are  two  methods  which  present 
themselves  to  our  notice: — 

The  first  consists  iu  adding  to  the  oil  various  resinous,  gummy  or  alkaline  sub- 
stances. Thus,  tar  may  be  added  to  ointments  constituting  ung.  picis.  Ung.  resiuse 
is  another  instance.  Powdered  gum  acacia  or  gum  tragacanth  will  also  markedly 
increase  the  adhesiveness  of  oils  which  dry  on  in  the  form  of  a solid  cake.  Insoluble 
powders  and  other  medicaments  will  act  slightly  in  the  same  way  if  used  with  ointments, 
where  they  would  no  doubt  act  mechanically  by  increasing  the  consistence  of  the  appli- 
cation. Glycerine,  too,  although  not  capable  of  permanently  mixing  with  fluid  oils, 
when  incorporated  with  ointments  increases  their  adhesive  properties. 

Combinations  of  this  kind  merely  act  by  taking  a firmer  hold  of  the  epidermis; 
they  do  not  penetrate  the  cuticle  deeply,  and  are,  for  all  practical  purposes,  insoluble  in 
the  watery  fluids  derived  from  the  skin. 

The  second  method  consists  in  making  use  of  gums  in  order  to  combine  or  emulsify 
a fat  or  oil  with  water  in  such  a manner  that  the  repulsive  force  exercised  upon  the 
watery  secretions  and  discharges  of  the  skin  is  either  partially  or  entirely  overcome. 
Even  water  or  medicated  solutions  alone  will,  to  a slight  extent,  effect  the  same  pur- 
pose when  thoroughly  incorporated  with  ointments. 

An  application  of  this  description  is  not  merely  extremely  adhesive,  but  when  pre- 
pared in  the  manner  described  is  also  soluble  in  all  proportions  in  water  and  watery 
fluids. 

Adhesive  preparations,  unlike  oils  or  fats,  tend  to  arrest  skin  action.  This  is  par- 
ticularly the  case  with  such  substances  as  varnish,  tar  or  collodion,  which,  owing  to 
their  being  totally  unacted  upon  by  the  secretions  or  to  their  inability  to  penetrate  the 
cuticle,  form  an  impervious  covering.  Every  one  is  doubtless  aware  when  an  animal 
happens  to  receive  a coat  of  varuisli  which  is  allowed  to  remain  on  its  body  that  death 
will  speedily  occur,  on  account  of  the  total  abolition  of  all  the  cutaneous  functions. 

Ointments  prepared  by  adding  to  them  adhesive  substances  to  some  extent  diminish 
skin  action  but  do  not  abolish  it.  The  presence  of  the  fat  will  prevent  the  arrest  of 
cutaneous  functions  on  the  one  hand,  while  on  the  other  the  adhesive  ingredients  serve 
to  neutralize  the  increased  functional  activity  which  would  be  produced  by  the  use  of 
the  uncombined  oil. 

The  well-known  use  of  white  lead  paint  in  the  treatment  of  erysipelas  may  be 
taken  as  an  instance  of  this  form  of  skin  medication.  Many  of  these  adhesive  bodies 
are,  however,  of  a more  or  less  irritating  character,  and  they  are,  consequently,  unsuited 
to  the  generality  of  skin  diseases  of  an  irritable  or  inflammatory  nature,  although  for 
indolent  ulcers  and  similar  lesions  which  require  much  stimulation  they  answer  admir- 
ably. 

Should  the  preparation,  as  is  the  case  with  an  oil  when  emulsified  with  gum  and 
water,  be  one  that  is  soluble  in  perspiration,  or  in  the  case  of  disease,  in  serum,  then, 
provided  it  be  without  irritating  properties,  this  same  neutral  action,  which  is  so  con- 
ducive to  local  rest,  will  be  made  manifest,  and  the  functional  activity  of  the  skin  will 


188 


NINTH  INTERNATIONAL  MEDICAL  C’ONGRESS. 


neither  be  augmented  nor  annulled.  This,  to  my  mind,  is  the  end  to  he  attained  in 
respect  to  external  applications  suited  to  inflamed  conditions  of  the  skin,  when  the 
soothing  and  healing  properties  of  sedative  or  mildly  stimulating  medicaments,  and  the 
sheathing  and  emollient  qualities  of  the  gum-encased  particles  of  oil  are  brought  into 
action,  in  a soluble  medium,  with  the  greatest  possible  degree  of  benefit  to  the  affected 
parts. 

Such  applications,  or  in  other  words,  well-made  emulsions,  resembling  milk  or  cream 
in  appearance,  while  perfectly  soluble  in  watery  fluids,  are  also  markedly  adhesive, 
and  the  remedies  I use  consist  of  emulsions  which  are  prepared  by  combining  an  oint- 
ment basis  (preferably  a mineral  fat)  with  water,  a vegetable  gum  and  a suitable 
antiseptic. 

It  has  been  my  practice  hitherto  to  use  boracic  acid  for  this  purpose.  It  preserves  the 
gum  from  decomposition  and  at  the  same  time  neither  irritates  the  skin  nor  in  anyway 
interferes  with  the  action  of  other  medicaments  when  used  with  it  in  the  emulsion. 

For  example  : Supposing  soft  paraffine  to  be  selected  as  the  ointment  basis.  One 

ounce  of  this  substance  is  placed  in  a mortar  previously  warmed,  and  incorporated  with 
160  grs.  (or  thereabouts)  of  powdered  gum  acacia.  About  half  an  ounce  of  hot  water 
is  then  added  and  the  whole  is  stirred  until  emulsified.  Boracic  acid  in  powder  is 
mixed  in  and  the  emulsion  is  diluted  with  water  until  a mixture  of  the  consistence*bf 
thick  cream  is  obtained. 

The  formula  will  stand  as  follows  : — 

Paraffine  molle,  1 oz. 

Pulv.  gum  acacia,  160  grs. 

Boracic  acid,  16  grs. 

Water  to  make  about  2 ozs. 

Suitable  medicaments  can  be  added  to  the  above  formula,  or  to  a formula  made  with 
other  ointment  bases,  and  made  use  of  according  to  the  disease  to  be  treated,  such  as 
subnitrate  of  bismuth  and  oxide  of  zinc  in  eczema,  sulphur  and  balsam  of  sulphur  in 
scabies,  salicylic  acid  in  lupus,  and  so  on. 

Smeared  over  the  skin,  emulsions  after  a Variable  time  form  a film  or  crust  of  pecu- 
liar character,  which  is  flexible  from  contained  oil  and,  adhering  closely  to  the  surface, 
effectually  protects  the  eruption  from  atmospheric  influences.  The  emulsion  compound 
is  capable  of  penetrating  the  scabs  or  crusts  of  certain  cutaneous  diseases,  and  of  mix- 
ing with  the  serous  discharges  of  superficial  wounds,  the  coagulative  power  of  which  is 
increased  thereby.  By  the  use  of  antiseptic  ingredients  the  parts  can  be  kept  per- 
fectly aseptic,  and  the  various  medicaments  that  are  used  with  the  emulsions,  dissolved 
or  suspended  as  they  are  in  a soluble  menstruum,  have  the  best  possible  opportunity  of 
exercising  a beneficial  influence. 

Under  such  conditions  inflammatory  action  will  become  rapidly  allayed,  and  the 
distressing  and  intolerable  irritation  which  so  frequently  accompanies  a subacute  or 
chronic  eczematous  condition  of  the  skin  will  be  speedily  and  usually  permanently 
relieved. 

It  is,  of  course,  necessary  to  leave  the  affected  parts  alone  and  undisturbed  as  much 
as  possible  by  keeping  them  at  rest,  and  by  refraining  from  the  usual  ablutions  with 
water  or  soap  and  water,  until  all  traces  of  discharge  have  disappeared,  and  the  scabs 
have  become  spontaneously  detached,  and  one  of  the  principal  points  to  which  I 
would  call  particular  attention  is  that  by  the  employment  of  these  preparations  it  is 
absolutely  unnecessary  to  resort  to  the  use  of  all  lint  and  textile  dressings,  since  being 
of  an  adhesive  nature,  they  constitute  perfect  dressings  in  themselves. 

In  conclusion,  permit  me  to  add  that  although  gum  emulsion  will  not  displace  older 
methods  of  treatment,  yet  I am  sanguine  enough  to  believe  that  we  have  in  them  a 
very  valuable  addition  to  Dermatology.  Should  these  observations  of  mine  relative  to 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


189 


the  use  of  these  applications  be  still  further  confirmed  by  the  extended  experience  of 
others,  I cannot  help  thinking  that  my  brother  practitioners  will  have  a new  power 
at  their  command  with  regard  to  the  treatment  of  many  cutaneous  disorders  which  are 
not  only  greatly  dreaded  by  the  public  at  large,  hut  when  once  set  up  are  often  intract- 
able under  ordinary  treatment. 

DISCUSSION. 

Dr.  Unna,  at  the  President’s  request,  spoke  at  some  length  upon  cutaneous 
varnishes  in  general.  He  classified  them  according  to  their  greater  or  less  permea- 
bility to  water,  and  according  to  their  volatility. 

Group  1. — Elasticiu,  gutta-percha  solution,  oleate  of  aluminium,  etc. 

Group  2. — Solutions  of  resins,  waxes,  fats  and  oleates,  in  alcohol,  ether,  benzine, 
chloroform,  mixtures  (myrrh,  rhubarb),  spiritus  saponatus,  etc. 

Group  3. — Emulsions,  soap  solutions,  etc. 

Group  4. — Water-glass, — gelatine,  dextrin,  albumen  and  rubber  solutions. 

Knaggs’  emulsion  appears  to  belong  to  the  third  class.  It  is  no  new  “ method  ” 
in  the  treatment  of  skin  diseases,  but  a new  and  probably  very  excellent  basis  for 
the  varnishes  which  have  long  been  used  in  dermatological  practice.  The  emulsifying 
of  vaseline  with  gum  arabic  is  new,  however. 


A NEW  METHOD  OF  TREATING  THE  VEGETABLE  PARASITIC 
DISEASES  OF  THE  SKIN. 

NOUVELLE  METHODE  POUR  TRAITER  LES  MALADIES  DE  PEAU  PARASITAIRES 

VEGETALES. 

UBER  EINE  NEUE  METHODE  IN  DER  BEHANDLUNG  DER  DURCII  PARASITARE  PILZE 
VERURSACHTEN  HAUTKRANKHEITEN. 

BY  HENRY  J.  REYNOLDS,  M.D., 

Chicago,  111. 

My  paper  will  refer  to  the  treatment  of  what  are  commonly  known  among  derma- 
tologists as  the  vegetable  parasitic  diseases,  viz.,  tinea  favosa,  tinea  versicolor  and  the 
three  forms  of  tinea  trichophytina.  As  the  form  of  tinea  tricopbytina  known  as  tinea 
circinata,  or  ordinary  ringworm,  and  tinea  versicolor  are  very  superficial,  they  are  there- 
fore readily  cured  by  any  of  the  ordinary  methods.  The  method  I am  about  to  describe 
will  therefore  be  more  applicable  to  those  wherein  the  deeper  structures,  as  the  hair 
follicles,  etc  , are  involved,  viz.,  favus,  ringworm  of  the  scalp  and  barber’s  itch.  Though 
I in  the  latter  diseases  many  methods  of  treatment  at  different  times  have  been  suggested 
and  tried,  they  are  nevertheless  very  stubborn  to  treatment,  particularly  so  unless  all 
the  diseased  hairs  be  systematically  removed.  For  this  reason  I feel  warranted  in 
i assuming  that  a suggestion  regarding  a method  which,  to  me,  bids  fair  to  be  preferable 
to  any  other,  and  which  has  never  before,  to  my  knowledge,  been  referred  to,  will  be 
tolerated,  as  also  a brief  report  of  the  few  cases  which  I have  treated  in  this  manner. 

The  great  object  in  all  methods  is  to  apply  the  parasiticide  in  such  a manner  as  to 
insure  its  penetration  to  the  bottom  of  the  hair  follicles  and  into  the  hair  structure 
itself  beneath  the  surface  of  the  skin.  Theoretically,  and  I think  practically  likewise, 
the  method  I am  about  to  describe  accomplishes  this  purpose. 


190 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


There  is  a long-recognized  law  in  electro-physics  by  which  fluids  in  a galvanic  cur- 
rent move  from  the  positive  to  the  negative  pole,  and  it  has  been  demonstrated  years 
ago,  and  over  and  over  again,  that  the  absorption  of  medicinal  substances  may  be 
induced  by  applying  this  principle,  viz.,  by  applying  the  substance  to  be  absorbed  on 
the  positive  electrode,  placing  it  on  the  skin,  and  completing  the  circuit  by  placing  the 
negative  electrode  on  some  other  part  of  the  body.  This  is  perhaps  best  substantiated 
by  the  fact  that  a solution  of  cocaine  applied  to  the  surface  of  the  sound  integument  in 
this  manner  will  in  a very  few  minutes  so  permeate  the  skin  as  to  produce  complete 
local  anaesthesia  of  all  the  cutaneous  and  subcutaneous  structures  covered  by  the  posi- 
tive electrode,  upon  which  subject  I read  a paper  at  the  last  meeting  of  the  American 
Medical  Association  ( Journal  American  Medical  Association , August  20th,  1887).  It  was, 
iu  fact,  in  making  these  local  anaesthesia  experiments  by  this  method  that  the  thought 
first  occurred  to  me  that  the  same  principle  might  be  used  to  advantage  in  the  treat- 
ment of  these  very  stubborn  and  annoying  maladies. 

The  means,  then,  employed  by  the  method  which  I am  about  to  describe,  to  induce 
the  penetration  of  the  parasiticide  remedy,  are  the  galvanic  current,  though  in  apply- 
ing the  method  it  is  possible,  if  not  probable  also,  that  the  electricity  itself  has  a salu- 
tary effect  upon  the  diseased  condition,  or,  in  other  words,  has  a destructive  influence 
upon  the  fungus  giving  rise  to  the  disease. 

With  your  permission,  I shall  now  proceed  with  a description  pf  the  method  as  I 
have  employed  it. 

Battery , Strength  of  Current , etc. — Though  not  an  expert  electrician  myself,  I believe 
it  is  an  established  fact  that  a large  number  of  small  cells  give  more  electrolytic  action 
than  the  same  area  of  large  cells.  I have  therefore  used  a battery  constructed  on  this 
principle — the  same  instrument,  in  fact,  which  I use  for  the  removal  of  superfluous 
hairs  by  electrolysis,  known  as  the  McIntosh  battery.  For  reasons  not  necessary  to 
discuss  at  present,  the  Faradic  current  will  not  answer,  neither  will  the  negative  pole 
of  the  galvanic.  The  strength  of  the  current  must  vary  with  the  sensitiveness  of  the 
part,  the  size  of  the  electrode,  etc.  It  is  always  necessary  to  use  the  strongest  current 
that  can  be  borne  without  discomfort  by  the  patient,  which,  with  the  battery  I use, 
when  in  good  order,  varies  from  five  to  ten  cells,  but  for  which  no  rule  can  be  laid 
down,  the  only  guide  being  the  feelings  of  the  patient  and  the  experience  and  discretion 
of  the  physician.  For  instance,  to  state  a given  number  of  cells  would  be  inaccurate, 
inasmuch  as  the  strength  of  the  cell  always  varies  with  the  freshness  of  the  battery 
fluid,  the  length  of  time  the  plates  have  been  in  use,  etc.  To  specify  the  strength  of 
current  as  so  many  milliamperes  would  be  unscientific,  without  giving  the  size  of  the 
electrode  or  stating  the  amount  of  the  resistance.  When  there  is  much  irritation  or 
hyperaemia  of  the  part  to  be  treated,  the  current  will  not  be  tolerated  so  strong,  and 
it  is  not  necessary  that  it  should,  as  there  is  then  less  resistance.  The  sponge  on  the 
electrode  used  for  the  parasiticide  solution  should  be  of  the  finest  and  softest  quality. 

3Iode  of  Application. — The  surface  to  be  treated  should  be  first  thoroughly  cleansed 
of  crusts,  scales  and  sebaceous  matter,  by  the  usual  process  of  oiling  and  washing  with 
soap  and  hot  water,  etc.,  and  if  thought  necessary,  of  course,  the  loose  hairs  may  be 
removed,  though  in  the  cases  I have  treated  this  was  not  done.  Saturate  the  sponge  of 
the  positive  electrode  with  whatever  parasiticide  lotion  is  preferred,  which  may  be 
aqueous,  alcoholic  or  ethereal,  and  place  it  directly  upon  the  part  to  be  treated.  Place 
the  negative  electrode  well  saturated  with  water  on  some  point  near  by.  A more  remote 
point,  as  tbe  hand,  for  instance,  will  answer,  but  it  will  take  longer  time  to  get  the 
same  effect  than  when  placed  near  by.  The  electrodes  should  be  kept  firmly  pressed 
to  the  skin,  the  positive  being  now  and  then  moistened  as  required,  with  more  of  the 
solution,  and  the  negative  with  more  water.  In  order  to  get  a sufficient  effect  the  posi- 
tive electrode  should  remain  on  each  diseased  patch  several  minutes  before  applying  it 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


191 


to  another  place  ; and  I think  on  the  scalp  it  is  not  wise  to  continue  the  treatment  over 
ten  or  fifteen  minutes  in  all  at  each  sitting,  and,  perhaps,  not  oftener  than  once  a day. 
The  parasiticide  used  in  the  cases  I treated  was  a one  per  cent,  solution  of  bichloride 
of  mercury. 

I had  hoped  to  be  able  to  report  a considerable  number  of  cases,  but  I have  as  yet 
only  been  able  to  treat  three  patients  by  this  method  ; one  of  favus,  and  two  of  tinea 
tonsurans. 

Case  i. — John  A.,  aged  seventeen,  otherwise  fairly  healthy,  was  first  seen  January 
12th,  1887.  Had  eruption  on  the  scalp  for  ten  years,  during  which  time  he  had  been 
treated  by  numerous  physicians  without  receiving  any  permanent  benefit.  To  confirm 
the  diagnosis  in  this  case  all  local  treatment  and  washing  of  the  scalp  was  ordered  sus- 
pended for  two  weeks.  January  26th,  examination  revealed  a patch  midway  between 
vertex  and  forehead,  about  two  inches  in  diameter,  covered  more  or  less  with  the  char- 
acteristic yellow,  sulphur- colored  crusts,  showing  in  many  places  distinctly  the  cup- 
shaped character  Hairs  dry,  brittle,  broken  off,  and  loose,  and  considerable  thinning  ; 
also  two  or  three  other  small  patches  similar  in  character.  Examination  with  the 
microscope  showed  the  crusts  to  be  composed  of  the  characteristic  spores  and  mycelia. 

The  part  was  thoroughly  cleansed  and  the  treatment  begun  as  described,  and  con- 
tinued daily.  In  addition  an  ointment  of  one  part  of  citrine  ointment  to  four  of  lard 
was  applied  every  night,  and  the  following  morning  the  scalp  was  thoroughly  cleansed 
preparatory  to  the  electrical  treatment.  This  treatment  was  carried  out  daily  till  Feb- 
ruary first.  The  patient  was  not  again  seen  until  the  latter  part  of  May,  when  he  was 
found  to  be  entirely  free  from  the  disease. 

Case  ii. — Mary  L.,  aged  ten,  applied  for  treatment  February  21st,  1887.  Had  scaly 
patches  on  scalp  for  four  years,  one  patch  in  region  of  parietal  eminence  of  right  side, 
about  two  inches  in  diameter,  and  two  other  smaller  patches.  Hairs  broken  off,  etc. 
Microscope  revealed  the  trichophyton  in  and  around  the  hairs.  Treatment,  same  as  case 
one,  except  that  no  ointment  was  applied,  was  continued  almost  daily  for  three  weeks. 
J une  12th,  patient  has  had  no  treatment  since  March  14th,  and  has  been  well  ever 
since. 

Case  ill. — Susan  L.,  aged  twelve,  sister  to  Case  ii,  applied  for  treatment  at  same 
time.  Had  the  disease  similar  to  her  sister — though  to  not  quite  the  same  extent — for 
two  years  and  a half.  Diagnosis  also  verified  with  the  microscope.  Treatment  com- 
menced at  the  same  time  as  her  sister,  and  continued  in  the  same  manner  for  the  same 
length  of  time.  Cured. 

Though  I have  been  unable,  from  the  very  limited  number  of  cases  treated,  to  deter- 
mine to  my  entire  satisfaction  the  full  merits  of  the  method,  or  the  comparative  merits 
of  this  and  other  methods,  I am  nevertheless  satisfied  that  I accomplished  results  in 
these  cases  that  could  not  have  been  done  by  any  other  line  of  treatment,  and  I there- 
fore feel  warranted  in  recommending  its  adoption  by  those  in  dermatological  practice, 
and  I feel  convinced  that  with  further  experience,  more  extended  observation,  and  the 
more  general  adoption  of  the  method,  it  will  be  found  superior  to  all  others  that  have 
been  tried. 


DISCUSSION. 

Dr.  Thin  said  he  had  been  impressed  with  the  great  variety  of  remedies  found 
in  literature  reputed  to  cure  tinea  tonsurans  quickly.  He  regarded  the  strong  solu- 
tion of  bichloride-  of  mercury  as  dangerous  to  life,  and  also  likely  to  cause  permanent 
baldness,  although  it  was  the  most  likely  remedy  to  cure  the  disease. 

He  has  seen  cases  of  ringworm  of  the  scalp  which  have  resisted  for  months  and 
months  the  usual  methods  of  treatment,  and  he  believes  there  is  no  one  method  that 
will  cure  the  disease  quickly  in  all  cases. 


192 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Dr.  Davis,  of  London,  thought  that  in  America  skin  diseases  were  more  easily 
cured  than  in  England,  from  the  report  of  rapid  cures,  especially  of  ringworm  and 
the  like. 

Dr.  Ronf:  thought  perhaps  the  differences  in  results  were  due  to  the  differ- 
ences in  application.  He  thought  the  bichloride,  in  solution  of  1 to  1000,  sufficient 
if  applied  often  enough,  before  new  spores  had  an  opportunity  to  be  produced. 
Fully  developed  organisms  resist  agents  much  less  than  spores.  So  long  as  one  spore 
remains  undestroyed,  so  long  will  the  danger  last.  The  hyposulphite  of  soda  will 
destroy  in  a short  time  the  organism  of  tinea  versicolor. 

Dr.  McGuire,  of  Louisville,  had  obtained  good  results  in  the  treatment  of  ring- 
worm from  the  use  of  chrysarobin  in  gutta  percha. 

Dr.  Ravogli  said  that  more  rapid  cures  can  be  obtained  if  epilation  is  practiced, 
as  then  the  remedy  employed  can  be  brought  into  more  direct  contact  with  the 
organisms  in  the  hair  follicles. 

Dr.  Yeamans  said  the  whole  matter  turned  upon  whether  we  can  or  cannot  reach 
the  spores.  He  believed  that  it  was  unnecessary  for  any  case  of  favus  to  exist  under 
proper  scientific  treatment  for  over  four  weeks,  epilation  being  practiced  daily. 

In  closing  the  discussion,  Dr.  Reynolds  said  he  had  nothing  further  to  add  ; the 
subject  had  been  very  thoroughly  discussed,  though  a great  deal  of  the  discussion  was 
not  pertinent  to  the  question.  He  said  it  was  well  known  to  every  dermatologist  that 
almost  any  parasiticide,  when  applied  so  as  to  reach  the  fungus,  would  destroy  it ; this 
was  demonstrated  by  the  fact  that  when  the  disease  was  superficially  located,  as  in  ordi- 
nary ringworm  or  tinea  circinata,  the  local  application  of  the  parasiticide  would  cure 
it.  Then  the  object  of  the  method  was  to  induce  the  absorption  or  penetration  of 
the  parasiticide  into  the  bottom  of  the  hair  follicles  and  into  the  hair  structure 
beneath  the  surface  of  the  skin.  Now  it  is  becoming  a well-known  fact  that  cocaine 
applied  in  this  manner  would  so  penetrate  the  skin  as  to  render  every  portion  of  the 
cutaneous  structure,  follicles  and  all,  anaesthetic.  Now  the  drug  must  in  all  prob- 
ability be  brought  in  contact  with  all  the  tissues  to  produce  this  result,  and  reasoning 
by  analogy  he  would  attempt  in  this  way  to  show  that  the  parasiticide  would  prob- 
ably do  the  same  thing,  and  such  being  the  case,  would  cure  the  disease  when  situ- 
ated in  the  bottom  of  the  hair  follicles,  as  it  does  in  disease  of  the  non-hairy  skin. 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGRAPHY. 


193 


THIRD  DAY. 


ZUR  KENNTNISS  DER  IMPETIGO  HERPETIFORMIS. 

A CONTRIBUTION  TO  THE  KNOWLEDGE  OF  IMPETIGO  HERPETIFORMIS. 

UN  TRAITE  SUR  L’lMPETIGO  HERPETIFORME. 

VON  DR.  JOSEPH  ZEISLER, 

Chicago. 

Wenn  zur  Behandlung  einer  Krankheit  eine  grosse  Zahl  von  Arzneimitteln  empfohlen 
1st,  so  pflegt  dies  gewbhnlich  eiu  Zeichen  dafiir  zu  sein,  wie  unsicher  unser  therapeu- 
tisches  Handeln  in  dem  Falle  ist ; ahnlich  scheint  es  ruir  mit  der  pathologisclien  und 
klinischen  Erkenntniss  einer  Affection  bestellt  zu  sein,  zu  deren  Bezeichnung  von  fast 
jedem  neuen  Beobachter  ein  neuer  Name  gewahlt  worden  ist.  Speciell  gilt  dies  von 
der  Krankheit,  die  den  Gegenstand  nieiner  Mittheilung  bildet. 

Unter  der  sehr  characteristischen  Benennung  “ Herpes  vegetans,”  zuerst  von  Auspitz 
im  Jahre  1869  beschrieben,  * wurde  die  Affection,  auf  Grund  von  fiinf  klinischen 
Beobachtungen,  im  Jahre  1872  von  Hebra  zuerst  als  “Impetigo  herpetiformis” 
bezeichnet ; | sp'ater  (1873)  folgten  die  Namen  “Herpes  pyaemicus  ” und  “Herpes 
puerperalis”  durch  Neumann.  J Einige  zweifellos  hierher  gelibrige  Falle  von  wahr- 
scheinlich  milderem  Character  werden  als  “ Herpes gestationis ” (Bulkley)  und  “Hydroa 
gestationis”  (Smith)  beschrieben.  In  seinem  “System  der  Hautkrankheiten  ” § giebt 
Auspitz  den  friiher  von  ihm  gew'ahlten  Namen  auf  und  ersetzt  ilin  durch  eine  Variante 
des  Hebra’schen,  “ Herpes  impetiginosus.  ” Unna||  critisirte  in  einer  trefflichen  Arbeit 
liber  “Impetigo  contagiosa,  nebst  Bemerkungen  liber  pustulose  und  bullcise  Haut- 
alfectionen,  ” auf  Grund  von  anatomischen  Betrachtungen  die  Berechtigung  des  Namens 
Impetigo  herpetiformis,  iiberliess  es  jedocli  der  Zukunft  und  besserer  atioliogischer 
: Erkenntniss,  einen  passenderen  Namen  zu  w'ahleu.  Duhring  hat  das  unbestrittene 

!Verdienst,  fur  die  in  Frage  stehende  Krankheit  neues  und  lebhaftes  Interesse  erweckt 
zu  haben  ; unter  Festhaltung  eines  von  alien  friiheren  Beobachtern  verschiedenen 
Standpunktes  und  unter  wesentlich  breiterer  Auffassung  des  Krankheitsbegriffes  fiihrte 
er  den  Namen  “ Dermatitis  herpetiformis  ” ein,  von  der  er  mehrere  Varietaten  unter- 
schied,  darunter  eine  pustulose,  die  mit  der  Hebra’schen  Impetigo  herpetiformis 
■ identisch  sei ; in  einer  grbsseren  Reihe  von  Arbeiten  und  durch  Mittheilung  zahlreicher 
Krankengeschichten  versuchte  Duhring  seinen  Ansichten  Anerkennung  zu  verschaffen. 
Es  lag  urspriinglich  in  meinem  Plane,  an  dieser  Stelle  die  erwahnten  Arbeiten  Revue 
^ paasiren  zu  lassen  und  die  Berechtigung  von  Duhring’s  Stellung  zu  untersuchen. 
;i  Seither  sind  aber  maassgebendere  Autoren  dieser  Aufgabe  gerecht  geworden  und  ich 
) darf  mich  daher  diesbeziiglich  kurz  fassen.  Zuniichst  hat  Bulkley  im  Vorjahre 


* Arch.f.  Derm.  u.  Syph.,  1869,  pag.  247.  ji  1880,  pag.  73. 

!f  Wien.  Medic.  Wochenechrift,  1872,  No.  48.  ||  Viertelj.  f.  D.  u.  S.,  18S0,  pag.  13  u.  fl'. 

t Lehrbuch,  1873,  pag.  185.  Journ.  G.  it.  Ven.  D.,  April,  1886. 

Vol.  IV— 13 


194 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


sowolil  den  von  Dukring  gewiihlten  Namen,  als  auch  die  Zusammenfassung  von  so 
vielen  versclnedenartigen  Proeessen  unter  eineni  Begriffe  angegriffen  ; dann  aber  hat 
Kaposi  in  einer  ganz  kiirzlieh  erschienenen,  ausgezeichneten  und  erschbpfenden  Arbeit  * 
seine  gewiclitige  Stimme  erlioben  und  vor  Verwirrung  in  der  der  Kliirung  so  bediirf- 
tigen  Frage  gewarnt ; diese  Arbeit  ist  wohl  jedem  Interessirten  zu  frisch  im  Gedlicht- 
nisse,  als  dass  ick  es  niithig  hiitte,  auf  dieselbe  niiher  einzugehen.  Wenn  sich  aueh  so 
Manches  gegen  den  Namen  Impetigo  herpetiformis  einwenden  lilsst,  so  liegt  vorlaufig 
kein  Grand  vor,  denselben  aufzugeben,  so  lange  kein  be&serer,  das  Wesen  der  Krankheit 
deutlicher  bezeiclinende  Name  zur  Yerfiigung  steht ; dies  mag  erst  der  Fall  sein,  wenn 
wir  der  Aetiologie  dieser  bislang  so  rathselhaften  Affection  niiher  geruckt  sind.  Eines 
seheint  mir  aber  dock  schon  heute  ziemlich  allgemein  adoptirt  zu  sein:  dass  der  von 
Hebra  als  Impetigo  herpetiformis  beschriebene  Process  durch  das  ganze  klinische  Bild, 
das  bisher  fast  regelmassige  Auftreten  bei  Weibern  und  deu  meist  nachweisbaren 
Zusammenhang  init  dein  Puerperium,  den  letalen  Ausgang,  die  so  characteristischen 
und  kaum  zu  verkennenden  Hautefllorescenzen  sich  von  alien  anderen  wohlbekannteu 
Dermatosen  so  plastisch  abhebt,  dass  es  kaum  am  Platze  sein  kanu,  denselben  mit 
anderen,  so  ganz  und  gar  verschiedenen  Affectionen  in  einen  Topf  zu  werfen.  Fast 
seheint  es,  als  ob  Systemen  und  Namen  in  unserem  Specialfache  zu  viel  Bedeutung 
beigelegt  wurde  ; die  Mijglichkeit,  eine  durch  besondere  nosologische  Eigenschaften 
ausgezeichnete  Krankheit  von  anderen  scharf  abzugrenzen,  ist  wohl  die  wichtigere 
Aufgabe. 

Die  folgende  Beobachtung  soli  nun  dazu  beitragen,  ein  weiteres  Beispiel  zu  der  von 
Hebra  aufgestellten  Form  zu  liefern. 

Am  20.  Januar  1885  wurde  ich  auf  giitige  Veranlassung  von  Prof.  C.  Fenger  zu 
Frau  Rosa  Unger  wegen  einer  angeblich  sehr  schmerzhaften  Lippenaffection  gerufen 
und  erhielt  damals  die  folgenden  anamnestiseken  Daten  : 

Die  Patientin,  28  Jahre  alt,  aus  Ungarn  gebiirtig,  ist  seit  etwa  sieben  Jahren  in 
diesem  Laude,  seit  sechs  Jahren  verkeirathet  und  hat  wiihrend  dieser  Zeit  drei  Kinder 
geboren,  von  denen  zwei  am  Leben  und  vollkommen  gesund  sind.  Sie  selbst  soil  bis 
zur  gegenwartigen  Erkrankung  sich  stets  des  vollkommensten  Wohlseins  erfreut  haben. 
Die  Menses  waren  seit  jeher  sehr  reichlich  und  sollen  in  der  letzten  Zeit  jedesmal  acht 
Tage  gedauert  haben.  Die  gegenwiirtige  Erkrankung  hat  vor  dreieinhalb  Monaten 
mit  Halssckmerzen  begonnen.  Bald  darauf  wurden  die  Lippen  wund  ; es  bildeten 
sich  auf  denselben  Ivrusten,  nach  deren  Entfernung  stets  starkes  Bluten  erfolgte,  ohne 
dass  jedoch  anfanglich  erhebliche  Schmerzen  bemerkt  wurden.  Nachde-m  durch  einen 
Monat  eine  Anzahl  von  Hausmitteln  erfolglos  versucht  worden  war,  wurde  hierauf  eine 
ganze  Reihe  von  Aerzten  consultirt,  ohne  auch  nur  Linderung  der  inzwisclien  sehr 
heftig  gewordenen  Schmerzen  zu  erreichen  ; im  Gegentheil,  die  Affection  breitete  sich 
auf  die  Mund-  und  Nasenschleimhaut  aus,  und  an  dem  rechten  Zeigefinger  und  der 
grossen  rechten  Zehe  traten  Nagelbettentzundungen  auf.  Als  Erganznng  dieser 
Angaben  wurde  — allerdings  erst  einige  Wochen  spa  ter  — in  Erfahrung  gebraclit,  dass 
das  dritte,  vor  einem  Jahre  geborene  Kind  bei  seiner  Geburt  nicht  niiher  beschriebene 
Hautausschl'age  gehabt  haben  soli,  besondors  auch  ad  anum,  dass  das  Kind  an  starkem 
Nasenbluten  gelitten  haben  soli  und  nach  acht  Wochen  zu  Grunde  gegangen  sei. 
Diese  Mittheilung  war,  wie  begreiflich,  nicht  wenig  geneigt,  die  Auffassung  des  Falles 
zu  compliciren  und  an  Lues  denken  zu  lassen.  Aber  es  sei  schon  an  dieser  Stelle 
liervorgehoben,  dass  sehr  sorgfaltige,  in  dieser  Richtung  angestellte  Nachforschungen 
dieses  iitiologische  Moment  sehr  zweifelhaft  erscheinen  liessen.  und  sei  noch  erwahnt, 
dass  der  Gatte  stets  vollkommen  gesund  gewesen  und  geblieben  war.  Der  Geburt  des 
genannten  Kindes  sollen  durch  einige  Monate  starke  Uterinblutungen  gefolgt  sein, 


* Viertelj.  f.  D.  u.  S.,  18S7,  n.  Heft. 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGRAPHY. 


195 


welche  endlicli  (lurch  arztliche  Intervention  zum  Stillstand  gebracht  wurden.  Mit 
diesem  Aufhiiren  der  Blutungen  bringt  Patieutin  das  gegenwartige  Leiden  in  causalen 
Zusammenhang. 

Stat.  pries  : 20. , I. , 85.  Die  Ivranke  ist  eine  wohlgeniihrte,  recht  kraftig  aussehende 
Frau  mit  reickliehem  Fettpolster.  Die  Haare  hellbraun,  die  Augeu  blaugrau.  Auf 
dem  behaarten  Kopfe,  in  der  Mitte  der  Scheitelgegend,  eine  etwa  thalergrosse,  von 
dicker,  schwappender,  gummiartiger  Kruste  bedeckte  Stelle,  nach  deren  Abhebung 
eine  vou  diinner,  sehmutzig-grauer,  eiter'ahulicher  Fliissigkeit  bedeckte,  duukelrothe 
Flache  sichtbar  wird.  Aehnliche  kleinere  Stellen  noch  sonst  auf  dem  Schadel,  dem 
Nacken  und  der  vorderen  Thoraxgegend.  Die  Naseneingiinge  durch  lockere  Krusten 
verklebt.  Beide  Lippen  durckaus  von  scliwarz  bis  hellbraun  gefiirbteu,  schildfdrmigen 
Borken  bedeckt,  die  leicht  als  Ganzes  abldsbar  sind,  wobei  massiges  Bluten  erfolgt 
und  die  ikrer  Oberhaut  entbldssten,  theils  blutendeu,  tkeils  grau weiss  belegten  Lippen 
sichtbar  werden,  die  nun  noch  viel  selimerzhafter  sind  als  zuvor.  Die  Inspection  der 
Mund-  und  Rachenhdhle  kann  in  Folge  heftiger  Schmerzeu  nur  unter  grossen  Schwierig- 
keiten  vorgenommen  werden.  Auf  der  Schleimhaut  derselben  zeigen  sick  durch 
serpigindse,  dunkel  injicirte  R'ander  scharf  abgegrenzte  Fliichen,  die  ihres  Epithels 
verlustig  sind  und  gleichsam  wie  verbruht  ausseken.  Sehr  starker  Fcetor  ex  ore.  Am 
reck  ten  Zeigefinger  besteht  eine  Nagelbettentz  undung,  durch  die  der  getrubte  Nagel 
theilweise  abgehoben  und  das  Fingerendglied  angeschwollen  und  schmerzkaft  ist.  Die 
Haut  der  Genito-Crural-Gegend  beiderseits  dunkel  gerothet,  stark  n'assend  und  zum 
Theile  von  blumenkohkihnlichen  Wucherungen,  breiten  Condylomen  nicht  unahnlich, 
besetzt.  An  der  Aussenseite  des  linken  Oberschenkels  eine  etwa  thalergrosse,  gleichsam 
excoriirte  Stelle.  An  der  rechten  grossen  Zehe  eine  von  dicker,  gummiartiger  Borke 
bedeckte,  etwa  centgrosse  Stelle.  Der  Harn  von  Eiweiss  und  Zucker  frei.  Die  Unter- 
suchung  der  inneren  Organe  ergiebt  normale  Verh'altnisse  ; jedoch  besteht  massiger 
Cervicalcatarrk.  Temperatur  37.8°  ; Puls  80. 

24.,  I.  Auf  dem  Riicken  und  der  Kreuzbeingegend  eine  reichliche,  frische  Eruption 
von  in  Gruppen  gestellten  Pusteln,  in  vollster  Entwicklung,  auf  dunkel  gerbtheter 
Basis,  sehr  ahnlich  Blatternefflorescenzeu.  Die  fr'uher  beschriebenen  Stellen  am  Ober- 
schenkel  und  der  grossen  Zehe  mit  fungdsen  W ucherungen  bedeckt. 

31.,  I.  Die  meisten  der  eben  genannten  Pusteln  abgetrocknet ; unter  den  Borken 
findet  sich  theils  eine  mit  j unger  Epidermis  bedeckte,  braunrothe  Fliiche,  theils  zeigt 
sich  eine  n'assende,  etwas  infiltrirte  und  mit  grauweissem  Exsudate  bedeckte  Stelle. 
Um  die  Zehennagel  kerum  Auftreten  von  miliaren  Pustelchen.  Der  rechte  Zeigefinger- 
nagel  von  seiner  Unterlage  ganz  abgehoben,  lasst  sich  leicht  entfernen.  Auch  mehrere 
andere  Fingernagel  zeigen  sich  getrubt,  offenbar  durch  unter  denselben  stattfindeude 

■ Exsudation.  Der  Zustand  an  den  Lippen  insofern  unveranclert,  als  sich  die  Krusten 
nach  Entfemung  sehr  rasch  wieder  erneuern. 

Vom  3.  bis  13.  Februar  befand  sich  die  Kranke  in  einem  Hospitale,  wo  das  Leiden 
fiir  Syphilis  gehalten  und  dem  entsprechend  behandelt  wurde,  ohne  jedoch  irgendwie 
/ giinstig  beeinflusst  zu  werden. 

13.,  ii.  Nachdem  im  Spitale  das  Ivopfhaar  abgeschnitten  worden,  zeigt  sich  nun 
die  Kopfliaut  in  grdsseren,  von  serpigindsen  Contouren  begrenzten  Strecken  erkrankt, 

j von  dickeu  Krusten  bedeckt,  unter  denen  die  oben  erw'ahnte  Beschaffenheit  sich  findet. 

H Das  periphere  Fortschreiten  des  Processes  kann  nun  sehr  deutlich  durch  an  den  R'andern 
1 sichtbare  Rothung  und  Schwellung  und  miliare  Pustelbildung  verfolgt  werden.  Der 
i;  Kopf  verbreitet  einen  bbchst  widerlichen  Geruch.  Lippen,  Muud- und  Rachenschleim- 
haut,  sowie  Naseneingange  wie  anfanglich  geschildert.  Au  der  Zungenspitze  eiuige 
i kleine,  fungdse  Wucherungen.  An  Hiinden  und  Fussen  verbreitet  sich  die  Krankheit 
in  centripetaler  Richtung  durch  iu  der  Peripherie  der  vorher  ergriffenen  Stellen  reichlich 
auftretende  miliare  Pustelchen.  In  aknlicker  Weise  breitet  sich  die  Affection  in  der 


196 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Genito-Crural-Gegend  nach  hinten  gegen  die  Crena  ani  und  nach  aussen  und  nnten  aus. 
Das  Endglied  des  rechten  Zeigeflngers  kolbenartig  angeschwollen,  sehr  schmerzhaft. 
Der  allgemeine  Kr'aftezustand  hat  sehr  abgenommen,  das  Fettpolster  ist  theilweise 
geschwunden,  der  Puls  klein,  schwach,  beschleunigt.  Wahrend  das  J ucken  entsprechend 
den  befallenen  Hautpartieen  nur  massig  ist,  wird  constant  liber  furchtbare  Schmerzen 
an  den  Lippen  geklagt,  die  Essen  und  Trinken  sehr  erschweren. 

Es  wiirde  zu  weit  f iihren,  wollte  ich  meine  seinerzeit  fast  taglich  gemachten  Notizen 
liier  recapituliren.  Ich  will  nur  summarisch  mittheilen,  dass  von  nun  ab  der  Process, 
ohne  deutliche  Etappen  einznhalten,  unaufhaltsam  fortschritt ; von  den  Fingern  ver- 
breitete  sich  die  Pustelbildung  uber  die  Handgelenke,  von  den  Zehen  iiber  die  Sprung- 
gelenke  hinaus  aus,  ebenso  von  der  Leistenbeuge  nach  alien  Richtungen  zu  ; neue 
Herde  zeigten  sich  in  den  Achselhdhlen,  in  den  Falten  unter  den  herabhlingenden 
Briisten,  um  den  Nabel  herum,  an  den  Ellenbogen.  Wahrend  friiher  das  Fortschreiten 
durch  Aufschiessen  von  niiliaren  Pustelchen  geschah,  zeigen  sich  jetzt  meisst  grii&sere 
Blasen,  oft  bis  zu  wallnussgross  ; die  Blasendecken  sind  diinn,  matsch,  erscheinen  oft 
schon  nach  vierundzwanzig  Stunden  braun  bis  schwarz  gefarbt.  Der  Blaseninhalt 
meist  dunnfliissig,  triibe  ; nach  Entfernung  der  Blasendecken  erscheint  das  dunkel- 
gerbthete  Rete  von  einer  dicken,  grau^eissen,  schtnierigen  Masse  oft  iiber  grdssere 
Strecken  hin  bedeckt,  die  sich  leicht  in  ganzen  Stricken  abheben  lasst.  Nun  bilden 
sich  an  diesen  Stellen  sehr  rasch  jene  oben  genannten  Yegetationen  aus.  Hie  und  da 
trat  auf  kleinen  Stellen  Ueberh'autung  ein.  Niemals  kam  es  zur  Ulceration.  Besser, 
als  ich  es  beschreiben  kdnnte,  werden  die  Abbildungen,  die  ich  Ihnen  hier  zeige  und 
die  der  citirten  Arbeit  Kaposi’s  entlehnt  sind,  den  damaligen  Zustand  der  Kranken 
illustriren  ; als  ich  diese  Bilder  zuerst  sah,  war  ich  von  der  colossalen  Aehnlichkeit  mit 
meinem  Falle  hdchst  frappirt.  Prof.  Hyde,  der  die  Kranke  am  1.  Marz  1885  mit 
Prof.  Allen  und  mir  sah,  zdgerte  nicht  einen  Moment,  die  Diagnose  Impetigo  herpeti- 
formis zu  stellen.  Der  Process  war  damals  in  vollster  Entwicklung  und  der  griisste 
Theil  des  Integumentes  mehr  weniger  ergriffen,  so  dass  an  ein  Verbinden  der  erkranktcn 
Stellen  kaum  zu  denken  war  ; ich  hatte  daher  die  Patientin  schon  seit  dem  25.  Februar 
in  ein  zu  dem  Zwecke  hergerichtetes  Wasserbad  gebracht,  in  dem  sie  den  grosster 
Theil  des  Tages  und  der  Nacht  zubrachte. 

Der  weitere  Verlauf  gestaltete  sich  nun  recht  trostlos.  Die  Kranke  wurde  immer 
schwacher  und  sckwlicher,  der  Puls  immer  kleiner  und  schneller.  Hie  und  da  schien 
f Ur  eine  Reihe  von  Tagen  Stillstand  einzutreten  ; dann  erschien  wieder  neuerliche, 
miichtige  Blasenbildung,  die  sich  immer  durch  Temperatursteigerung  und  einen  an  der 
Peripherie  der  alten  Plaques  auftretenden  erythematbsen  Saum  ankiindigte.  Am  i 
1 . April  trat  eine  complicirende  Peritonitis  uuter  Schiittelfrbsten  hinzu  ; die  Krauke 
wurde  bald  soporbs  ; vollkommene  Depression  wechselte  mit  heftigen  maniakalischen 
Zust'anden,  in  denen  sie  die  nachsten  Angehorigen  misshandelte  ; der  Puls  wurde  immer 
rascher,  bis  zu  160,  dabei  fadenformig,  und  unter  den  Erscheinungen  von  Geliirn- 
lahmung  starb  die  Krauke  am  Morgen  des  6.  April.  Eine  Autopsie  wurde  leider  nicht 
gestattet. 

Yon  der  Behandlung  babe  ich  bis  nun  nicht  gesprochen,  und  leider  habe  ich  dies-  - 
beziiglich  nichts  Erfreuliches  zu  berichten.  Gegen  die  Schmerzen  an  den  Lippen  wurde 
eine  ganze  Reihe  von  Salben,  Pulvern  und  Eiupinseluugen  mit  nur  voriibergehendem 
Erfolge  versucht ; selbst  fiinf  Procent  Coca'inlbsung  erwies  sich  ungeniigend.  Eben- 
sowenig  schien  die  topische  Behandlung  der  erkrankten  Hautstellen  irgend  einen  Ein- 
fluss  auf  den  Stillstand  oder  die  Riickbildung  des  Processes  zu  haben.  Salben  warden 
sehr  schlecht  vertragen  ; Jodoformpulver  schien  noch  am  ehesten  die  Schmerzen  etwas 
zu  lindern  und  den  bisweileu  furchtbaren  Gestank  an  den  Vegetationen  zu  vernichten. 
Das  Wasserbett,  in  dem  die  Patientin  mit  geringen  Unterbrechuugen  fast  fiinf  Wochen 
zubrachte,  erwies  sich  als  ein  wahrer  Segen,  denu  im  Bette  klebte  die  Kranke  fbrmlick 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGRAPHY. 


197 


an  ihren  Kissen  und  Linnen  an,  wahrend  sie  dort  sich  relativ  wold  f iihlte.  Zusatze 
von  Sublimat  und  Alcohol  zu  dem  Bade  schienen  olme  Effect  auf  die  Eiterungsprocesse 
an  der  Haut.  Die  interne  Behandluug  versuchte  theils  roborirend,  tbeils  umstimmend 
zuwirken  ; aber  wederEiseu,  noch  Arsen,  Secale,  Jodkalium  oder  Quecksilberpriiparate 
schienen  irgend  welchen  Eiufluss  auszuiiben,  und  so  kann  icli  denn  nur  sagen,  dass  die 
vou  mir  versuclite  Therapie  dieser  furchtbareu  Krankheit  vollkommeu  machtlos 
war. 


Was  nun  die  Diagnose  des  vorliegendeu  Falles  anlangt,  so  kann  f iir  Denjenigen, 
der  jemals  einen  ahnlichen  Fall  gesehen  oder  die  Beschreibungen  vou  Auspitz,  Hebra, 
Kaposi  gelesen  hat,  kaum  ein  Zweifel  sein,  dass  derselbe  ein  hiichst  klassisches  Beispiel 
der  Impetigo  herpetiformis  bildet.  Das  Auftreten  an  einem  weiblichen  Individuum, 
im  Anschlusse  au  eine,  wenu  auch  nicht  niiher  eruirte  Uterinaffection,  die  offenbar  vou 
dem  letzten  Puerperium  datirte,  die  characteristisclie,  gruppirte  Pustelbildung,  die 
Affection  der  Sehleimhiiute,  der  Nagel,  die  Localisation  des  Leidens,  die  beschriebenen 
Vegetationen,  der  rasche,  fast  unauf  haltsame  Verlauf,  sprechen  wohl  stark  genug  daf  iir. 
Ich  kann  nicht  verhehlen,  dass  beim  Lesen  einer  im  Vorjahre  aus  der  Feder  Neumann’s 
erschienenen  Arbeit  fiber  “Pemphigus  vegetans”*  mir  fur  einige  Zeit  Zweifel 
erwuchsen,  ob  ich  es  nicht  mit  dieser  seltenen  Form  des  Pemphigus  zu  tliun  gehabt ; 
aber  der  stets  eitrige  Inhalt  der  Blasen  und  Bliischen  in  meinem  Falle  spricht  dagegen. 
Jedenfalls  scheint  mir  eine  ausserordentliche  Verwandtschaft  zwischen  diesen  beiden 
Processen  zu  besteheu  und  eine  Differenzirung  derselben,  besonders  in  den  Anfangs- 
stadien,  zu  den  scliwierigsten  Aufgaben  der  Diagnostik  zu  gehbren.  Von  einzelnen 
Beobachtern  wird  ja  direct  ein  Uebergehen  der  Impetigo  herpetiformis  in  Pemphigus 
berichtet,  wie  z.  B.  in  dem  Falle  Heitzmann’s,  * der  allerdings  von  Auspitz  und  Kaposi 
anders  gedeutet  wird.  Den  von  Einzelnen  f iir  characteristisch  gehaltenen  Vegetations- 
bildungen  legen  Kaposi  und  Andere  keinen  diagnostischen  Werth  bei,  iudem  dieselben 
nur  als  der  Ausdruck  eines  bei  herabgekommenen  Individuen  gestiirten  Epidermis- 
ersatzes  gedeutet  werden.  Die  Mittheilung  eines  zum  ersten  Male  bei  einem  Manne 
beobachteten  Falles  durch  Kaposi  f unterbricht  die  bisher  geschlossene  Kette  einer 
allerdings  relativ  kleinen  Anzahl  von  nur  bei  Weibern  constatirten  Fallen  und  ist 
geeignet,  unsere  bisherigen  Ideen  iiber  die  Aetiologie  der  Krankheit  zu  stbren  ; andere, 
von  Duhring,  Robinson  J und  Anderen  mitgetheilte  gehbren  wohl  kaum  hierher. 
Weitere  Erfahrungen  miissen  hier  Klarung  bringen.  Es  kann  nicht  genug  betont 
werden,  wie  wichtig  die  Unterscheidung  derartiger  Fiille  von  Syphilis  ist,  und  was 
Neumann  am  Schlusse  der  oben  citirten  Arbeit  in  beredten  Worten  mit  Bezug  auf 
Pemphigus  vegetans  sagt,  gilt  wohl  auch  in  unserem  Falle.  Auch  in  dem  von  mir 
mitgetheilten  Falle  schien  Manches  aus  der  Auamnese  dafiir  zu  sprechen  ; aber  ■wie 
unverliisslich  sind  fur  gewbhnlich  die  Angaben,  die  wir  von  unseren  Patienten  erhalten, 
wie  verschwindend  unwichtig  gegen  Das,  was  wir  mit  unseren  Augen  sehen  ! Ob  ich, 
nach  Dem,  was  ich  mitgetheilt,  zu  der  Diagnose  Impetigo  herpetiformis  berechtigt  war, 
i muss  ich  dem  Urtheile  iilterer  und  erfahrenerer  Beobachter  iiberlassen. 

Dass  ich  mit  der  vorstehenden  Mittheilung  zur  Pathologie  und  Aetiologie  unserer 

3 Krankheit  nichts  Nennenswerthes  beigetragen  habe,  ist  mir  wohl  bewusst ; Falle  der 
Privatpraxis  kbnnen  eben  nicht  so  ausgenutzt  werden,  als  solche  in  Spitiilern.  Aber  da 
i bis  nun  eine  so  spiirliche  Anzahl  von  Beobachtungen  dieses  seltenen  Leidens  vorliegt, 
so  mag  meine  Absicht,  meinen  Fall  in  weiteren  Kreisen  zu  verbffentlichen,  berechtigt 
£ erscheinen. 


* Viertelj.f.  I),  u.  S.,  1886. 
f Amer.  Arch,  of  Derm..,  IV,  78. 


t L.  c. 

I J.  of  C.  & V.  D.,  1885. 


198 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


DISCUSSION. 

In  the  discussion  which  followed,  Dr.  Unna  related  a case  which  resembled  both 
impetigo  herpetiformis  and  dermatitis  herpetiformis,  but  differed  from  both  and  was 
probably  neither.  It  was  similar,  as  regarded  treatment,  in  that  iodine  in  abundance 
was  the  only  treatment  which  gave  good  results. 

It  resembled  more  an  impetigo,  because  the  blebs  appearing  did  not  from  the 
first  contain  pus,  as  is  necessary  to  establish  the  diagnosis.  He  believed  in  the  exist- 
ence of  a dermatitis  herpetiformis,  but  is  satisfied  that  the  impetigo  herpetiformis  of 
Hebra  is  a distinct  disease,  and  should  not  be  classed  by  Duhriug  with  the  other 
forms  which  go  to  make  up  his  dermatitis  herpetiformis. 


ON  .ETIOLOGY  AND  TREATMENT  OF  LUPUS  ERYTHEMATOSUS. 

SUR  L’ETIOLOGIIS  ET  LE  TRAITEMENT  DU  LUPUS  ERYTHEMATIQUE. 

UBER  DIE  ATIOLOGIE  UND  BEHANDLUNG  DES  LUPUS  ERYTHEMATOSUS. 

BY  A.  RAVOGLI,  M.D., 

Cincinnati,  Ohio. 

Before  this  honorable  body  of  scientists,  it  is  of  great  interest  to  me  to  introduce 
the  subject  of  Lupus  Erythematosus  (Cazenave),  which,  although  excellently  treated 
and  scholarly  illustrated  by  the  most  reputed  dermatologists,  I find  is  still  surrounded 
with  darkness.  Its  aetiology  is  in  darkness;  in  every  work  on  skin  diseases  we  find 
that  this  disease  may  be  produced  by  a large  number  of  different  causes,  and  yet  not 
one  of  these  opinions  can  stand  a severe  criticism.  The  opinion  of  its  being  a result 
of  a trophoneurosis  is  that  which  can  best  be  defended,  as  it  does  not  explain  much  and 
can  he  reduced  to  the  old  proverb,  obscura  obscurioribus  dilucidare. 

No  less  obscure  appears  to  me  the  knowledge  which  we  have  in  regard  to  the  inti- 
mate process  of  lupus  erythematosus,  which,  by  some,  has  been  referred  to  a neoplastic 
affection  and  ranked  with  lupus  vulgaris,  by  others  to  a cellular  infiltration  originating 
from  an  inflammatory  process  in  the  meshes  of  the  cutaneous  tissues. 

The  prognosis  and  treatment  go  hand  in  hand  with  our  other  knowledge,  and  we 
can  say  that  it  is  very  difficult  to  answer  the  question  of  the  patient  as  to  whether  he 
will  he  cured  and  how  long  the  treatment  will  last,  on  account  of  the  great  uncertainty 
in  the  remedies  recommended. 

In  my  opinion,  lupus  erythematosus  is  a kind  of  rock  in  our  medical  branch,  and 
I have  always  been  better  satisfied  to  have  to  treat  a case  of  lupus  vulgaris  than  one  of 
lupus  erythematosus. 

It  would  he  entirely  superfluous  for  me  to  give  a description  of  the  symptoms  of 
lupus  erythematosus  before  this  scientific  body,  or  to  describe  some  cases  of  the  disease. 
The  main  point  for  me  is  to  find  out  the  solution  of  the  question.  What  is  the  intimate 
process  of  lupus  erythematosus,  and  what  is  its  cause  ? 

I confess  that  the  solution  of  these  questions  has  been  a difficult  task,  hut  when  we 
agree  on  tUe  two  main  points,  I think  that  we  will  have  more  light  on  this  subject. 

Professor  Kaposi,  although  he  ranks  lupus  erythematosus  among  the  neoplasmata, 
next  to  lupus  vulgaris,  insists  upon  its  inflammatory  nature.  He  bases  his  views 
mostly  on  the  clinical  symptoms  which  he  ascribes  to  an  inflammatory  process. 


SECTION  XIV — DERMATOLOGY  AND  S YPH I LOG  R A PII Y . 


199 


When  Hebra  at  first  described  this  disease  as  seborrhoea,  he  originally  used  the 
modifier  congestiva,  from  its  most  prominent  symptom,  the  congestion.  The  same 
disease  has  been  described  by  Biett  with  the  name  ot  erythema  centrifugum,  and  all 
show  that  every  author  maintained  erythema  and  congestion  as  the  bases  ol  their 


Fig.  1. 


nomenclature.  The  erythema  is  seen  from  the  disappearance  of  the  redness  under 
pressure  of  the  finger,  and  its  reappearance  when  the  pressure  is  removed,  and,  in  some 
cases,  from  the  acute  inflammation  which  occasionally  accompanies  the  lupus  erythe- 
matosus discoides,  and  constantly  occurs  in  the  lupus  aggregatus. 

Fig.  2. 


The  few  figures  here  shown  have  been  chosen  from  several  specimens.  The  mate- 
rial has  been  cut  off  from  the  edge  of  a recent  spot  of  lupus  erythematosus  on  the  neck 
of  a gentleman  who  had  the  disease  for  about  three  years.  The  piece  of  skin  was  left 
for  two  days  in  alcohol  and  then  cut  for  examination  with  the  microscope. 


200 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  first  thing  which  I consider  remarkable  in  the  sections  is  the  hypertrophy  of  the 
epidermic  celts.  These  cells  are  enlarged  and  furnished  with  large  nuclei  and  abundant 
nucleoli;  even  in  the  most  superficial  portion  of  the  horny  layer,  where  the  nuclei  are 
not  frequently  perceptible,  they  are  swollen  and  enlarged.  Between  the  cells  we  do 
not  find  infiltration  cells,  but  the  only  change  is  the  hypertrophy  of  the  epidermic  cells. 
In  the  same  way  the  epidermic  cells  which  invest  the  interior  of  the  sebaceous  glands 
and  of  the  follicles  of  the  hairs  are  hypertrophic.  In  the  tissue  forming  properly  the 
stroma  of  the  corium,  we  see  that  the  papillae  are  of  a much  larger  size  than  in  the 
normal  condition,  and  an  infiltration  of  small  inflammatory  cells  is  spread  between  the 
fibres  of  the  connective  tissue.  The  most  striking  feature  is  the  hypertrophy  of  the 
fascicles  of  the  fibres  of  the  connective  tissue  constituting  the  stroma  of  the  papillae. 
The  corpuscles  of  the  connective  tissue,  which  in  the  skin  of  the  adult  are  no  longer 
perceptible,  are  seen  again,  furnished  with  their  nuclei  and  nucleoli,  as  at  an  embryonic 
stage.  The  elastic  fibres,  which  I believe  are  nothing  else  than  the  product  of  the 
fibres  produced  by  the  corpuscles  of  the  connective  tissue,  are  also  enlarged  and  swollen. 
When  we  look  at  the  structure  of  the  corium  in  Fig.  3,  we  find  that  the  loculi  formed 


Fig.  3. 


by  the  fibres  of  the  connective  tissue  are  exceedingly  enlarged,  and  they  ought  to  con- 
tain this  intercellulary  fluid  which  is  the  cause  of  the  hypertrophy  of  the  histological 
elements  of  the  skin. 

The  blood  vessels  are  enlarged  and  filled  with  blood  corpuscles. 

From  what  we  can  see  from  the  above  figures  we  must  be  persuaded  that  the  inti- 
mate process  of  lupus  erythematosus  is  not  a neoplastic  but  an  inflammatory'  one.  It 
was  at  first  believed  to  be  an  inflammation  of  the  sebaceous  glands  only,  but  we  can 
demonstrate  that  the  skin  in  all  its  elements  and  in  each  lay'er  is  affected. 

Lupus  erythematosus  leaves  the  skin  white,  thin,  like  parchment,  which  has  been 
considered  as  a scar.  A few  days  after  a spot  of  lupus  erythematosus  appears  we  see 
in  the  middle  of  the  spot  a depression  produced  by  the  atrophy'  of  the  elements  of  the 
skin.  This  does  not  surprise  us,  when  we  consider  the  intimate  process  of  lupus  ery- 
thematosus based  only  on  an  hypertrophy  of  the  connective  tissue  and  of  the  epidermic 
cells.  Any  element  of  the  living  body  when  surcharged  with  nutrition  and  advancing 
into  hypertrophy,  cannot  remain  in  this  condition,  and,  therefore,  in  the  excess  ot  the 
process  of  deuutrition,  becomes  shriveled  and  atrophic.  Kaposi  asserted  already  that 


' A-  )0  AGADEMX 

' . OF 

SECTION  XIV — DERMATOLOGY  A^fi"  SYPHILOGKAPHY.  201 

the  sear  following  lupus  erythematosus  was  uot  a cicatrix,  properly  speaking,  but  a local 
atrophy  of  the  skin.  In  the  midst  of  the  inflammatory  changes  of  the  tissues,  and  some- 
times at  an  early  age,  fatty  and  molecular  cloudiness  of  the  cells  ot  the  rete  and  of  the 
glands,  and  also  of  the  corpuscles  and  fibres  of  the  connective  tissue  take  place,  and  all 
shrivels  up,  with  the  result  of  a true  atrophy  of  the  skin.  The  cause  of  this  atrophy  I 
find  in  the  blood  vessels,  which,  being  compressed  by  the  infiltrating  cells  and  by  the 
hypertrophy  which  is  spreading  in  the  surrounding  skin,  are  closed  and  obliterated. 
The  same  process  of  hypertrophy  causes  the  obliteration  of  the  glands,  which  also,  at 
first,  participate  in  the  process  of  hypertrophy,  and  afterward  atrophy  like  the  other 
tissues.  The  connective  tissue  fibres,  after  the  atrophic  process  has  taken  place,  are 
thin,  shriveled  and  mixed  together  in  different  directions,  and  the  connective  tissue  cor- 
puscles are  no  longer  to  be  distinguished.  The  enlarged  loculi  are  diminished  and 
scarcely  perceptible.  The  whole  tissue  is  atrophic. 

This  is  the  end  of  the  process  which  we  call  lupus  erythematosus,  a process  which 
can  be  reduced  to  only  two  factors  : at  first  hypertrophy  of  the  histological  elements, 
and,  subsequently,  atrophy  of  the  same. 

But,  in  order  to  have  those  above-mentioned  effects  of  inflammatory  nature,  we  must 
admit  a primary  cause  which  is  capable  of  giving  rise  to  the  disturbance  of  the  nutri- 
tion of  the  cells.  The  greatest  factor  of  these  disturbances  is  irritation,  which  by  a 
heterogeneous  stimulation  of  the  nerves  increasing  the  blood  supply  in  the  vessels  aug- 
ments the  nutrition  and  causes  disturbance  in  the  biological  activity  of  the  cells. 

Kaposi,  in  treating  this  question,  remarked  that  in  many  cases  the  affection  begins 
as  a local  disease  and  runs  its  course  as  such  without  in  the  least  affecting  the  con- 
stitution during  the  whole  duration  of  the  malady.  He  refers  to  cases  in  which  lupus 
erythematosus  has  proceeded  from  a seborrhcea  of  the  nose  and  face,  which  had  its 
origin  in  the  scars  of  smallpox.  In  these  cases  he  says  there  is  not  the  least  induce- 
ment to  consider  it  as  a constitutional  disease.  He  furthermore  declares  that  lupus 
erythematosus,  although  pointed  out  by  many  authors  as  occurring  mostly  in  chloro- 
ansemic  women,  occurs  also  in  healthy  females  and  in  robust  and  vigorous  men. 

In  the  cases  where  lupus  erythematosus  shows  an  acute  general  eruption,  he  admits 
the  existence  of  a decided  sympathy  of  the  whole  organism.  He  sees  an  intimate  rela- 
tion between  the  inflammatory  process  of  the  skin  and  the  high  fever,  typhoid  state, 
pleuro-pneumonia,  affections  of  the  joints,  which  were  observed  in  those  unfortunate 
cases.  To  the  exacerbation  of  the  lupus  spots  he  refers  the  outbreak  of  the  erysipelas 
perstans  faciei.  He  regards  the  nervous  system  as  the  cause  of  all  the  trouble.  But 
the  results  of  the  autopsies  in  eight  cases  of  this  kind  did  not  authorize  the  opinion  that 
the  primary  cause  of  the  disturbance  lies  in  the  trophic  nerves  or  in  the  centre  of  the 
vasomotor  nerves. 

Here  we  are  again  in  darkness. 

Now  you  will  allow  me  to  discuss  my  specimens  again.  I have  taken  scales  from 
three  cases  of  lupus  erythematosus.  The  scales  have  been  macerated  from  one  to  two  hours 
in  a caustic  solution  of  potassa  and  then  carefully  washed  in  water,  then  colored  with 
hsematoxylon,  then  washed  again  in  a mild  solution  of  acetic  acid. 

What  impresses  us  at  first  is  the  presence  of  epidermic  cells  enormously  enlarged, 
containing  a large  number  of  small,  brilliant,  round  cells  (Fig.  4),  all  of  the  same  size, 
slightly  stained  by  the  hsematoxylon.  They  appear  to  be  microorganisms,  which  can 
be  designated  as  belonging  to  the  strongly  obligatory  parasites  of  de  Bary. 

In  Fig.  5 we  can  see  those  cells  separated  and  others  forming  groups  or  little,  colonies, 
which  gives  us  the  idea  that  they  were  contained  in  a cell  like  in  Fig.  4,  and  the  cell 
has  been  destroyed  by  the  caustic  potash,  leaving  the  microorganism  intact  in  its  place. 
The  resistance  to  the  action  of  the  caustic  potash  strengthens  us  in  the  opinion  of  their 
being  microorganisms  exhibiting  their  own  microbiotic  life. 


202 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


It  was  now  interesting  to  establish  whether  these  microorganisms  remain  on  the 
surface  of  the  epidermis  or  go  deeply  in  the  structure  of  the  skin. 

To  determine  this  I took  sections  of  skin  affected  with  lupus  erythematosus,  which 
had  beeu  previously  hardened  with  alcohol;  the  sections  were  treated  with  a solution 


Fin.  4. 


of  caustic  potash  and  boiled  in  it  from  a few  seconds  to  three  minutes.  The  section  so 
treated  was  washed  in  distilled  water  and  then  colored  partly  in  methyl  violet  and 
partly  in  vesuvine,  then  subjected  to  partial  discoloration,  either  in  distilled  water  or 
in  a solution  of  acetic  acid. 

Fig.  5. 


In  these  specimens  we  see  that  the  microorganisms  of  similar  size,  having  resisted 
the  caustic  potash  at  the  boiling  point,  colored  in  yellow-brown  by  the  vesuvine  and  in 
blue  by  the  methyl-violet,  are  ranged  in  chains  and  in  groups  in  the  layer  of  the  epi- 
dermis. The  epidermic  cells  have  been  almost  destroyed,  and  the  cocci  remain  in  their 
place.  Micrococci  we  find  in  the  papillary  layer  mostly  abundant  in  the  places  where 


SECTION  xrv — DERMATOLOGY  AND  SYPHILOGRAPHY. 


203 


some  exudation  exists.  Small  colonies  of  cocci  are  found  in  the  interior  of  the  fibres, 
and  some  are  found  also  in  the  capillary  blood  vessels. 

In  one  specimen,  where  the  tissues  have  been  nearly  destroyed  by  boiling  too  long 
in  caustic  potash,  the  microorganisms  are  much  more  apparent  and  abundant. 

Now  when  we  find  iu  a section  (Fig.  3)  masses  or  chains,  of  small  bodies  which  are 
of  similar  size,  and  which  withstand  both  the  action  of  alcohol  and  ether,  aud  the  treat- 
ment with  concentrated  acetic  acid,  and  the  alkalies  after  warming,  these  are  to  he 
considered,  according  to  Friendlander,  as  microorganisms.  There  is  no  doubt  that 
microorganisms  exist  in  lupus  erythematosus,  and  not  only  on  the  surface,  but  in  the 
structure  of  the  skin,  as  in  Fig.  3 is  clearly  seen.  The  question  now  is  to  try  cultivation 
and  inoculation  of  these  cocci,  which  I have  been  unable  to  do  up  to  the  present  time, 
for  want  of  material. 

Having  established,  then,  the  presence  of  the  coccus  in  this  disease,  it  seems  probable, 
reasoning  from  analogy,  that  we  have  here  the  essential  cause  of  the  affection.  This 
admitted,  the  intimate  nature  is  clearly  explained  in  lupus  erythematosus  discoides. 
In  the  other  kind,  called  aggregatus,  we  can  find  also  a better  explanation  by  the 
presence  of  the  micrococci.  Their  quantity  and  their  reabsorption  into  the  meshes  of  the 
skin  I think  to  be  the  cause  of  the  erysipelas  perstans  described  by  Kaposi,  and  the 
reabsorption  into  the  general  system  the  cause  of  the  severe  symptoms  which  may 
sometimes  cause  the  death  of  the  patient. 

What  about  the  treatment?  In  every  book  and  pamphlet  internal  remedies  are 
considered  of  no  effect  on  the  lesions,  only  in  case  of  trouble  in  the  general  system  are 
remedies  used  which  the  individual  case  may  require.  In  the  same  way  in  case  of 
lupus  erythematosus  aggregatus,  when  producing  erysipelas  and  general  systemic  symp- 
toms, these  remedies  are  used  accordingly. 

In  ordinary  cases  of  lupus  erythematosus  the  medication  is  limited  to  the  locality. 
The  application  of  emplastrum  hydrargyri  has  been  considered  as  one  of  the  best 
means,  combined  with  washing  with  spirit,  saponat.  kalin.  In  this  medication  every 
one  is  aware  that  we  are  dealing  with  powerful  antimycotic  agents.  I must  return  to 
the  theory  of  Cromoisy,  that  parasites  are  not  destroyed  by  the  remedy,  but  we  obtain 
the  result  on  account  of  the  necrosis  produced  on  the  epidermic  cells,  and,  consequently, 
their  desquamation.  With  the  tincture  of  soap  we  obtain  the  dissolution  of  the  epi- 
dermic cells,  and  with  the  application  of  the  emplastr.  hydrarg.  we  may  obtain  the 
destruction  of  the  microbes  by  the  production  of  some  sublimate  in  the  layer  of  the 
skin.  Caustics  were  used  very  profusely,  and  especially  iodide  of  mercury,  trichlor- 
acetic acid,  pyrogallic  acid,  chloride  of  zinc,  etc.  We  come  always  to  the  same  conclu- 
sion, when  we  destroy  the  skin  we  destroy  the  microbe  too,  and  a scar  will  replace  the 
destroyed  skin.  The  use  of  the  sharp  scoop  for  scraping  the  spots  of  lupus  erythema- 
tosus, I think  should  be  ranked  with  the  strong  caustics;  the  skin  having  been 
destroyed  it  will  be  replaced  by  scar  tissue.  But  if  this  would  always  occur,  I think 
we  would  be  very  happy.  I have  had  in  my  experience  cases  of  lupus  erythematosus 
where,  after  having  burnt  or  scraped  the  spot  and  a scar  followed,  lupus  canerosus 
appeared  on  new  spots,  or  almost  in  the  scar.  I thiuk  that  the  use  of  strong  caustics 
and  of  the  sharp  scoop  for  lupus  erythematosus,  must  be  very  limited,  if  not  entirely 
objectionable. 

After  the  introduction  of  ichthyol  by  Unna,  I tried  it  in  lupus  erythematosus,  and 
in  three  cases  obtained  complete  recovery.  Its  first  action  is  displayed  on  the  epidermis 
with  which  it  is  brought  in  contact,  and  appropriating  the  oxygen  of  the  cells  produces 
an  induration  of  the  epidermic  tissue.  . The  same  action  which  we  see  on  the  horny 
layer  is  produced  on  the  epithelium  investing  the  sebaceous  glands,  and  after  a few 
applications  we  see  diminution  of  their  secretion,  and  sometimes  the  hard,  dry  cells 
obstruct  the  opening  of  the  glands  and  pustules  result.  The  astringent  and  reduciug 


204 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


action  of  iclithyol  is  also  displayed  in  the  underlying  tissue  and  the  blood  vessels,  in 
diminishing  by  contraction  their  caliber.  In  the  same  way  as  we  see  the  redness  dis- 
appear after  a few  applications  of  this  remedy  in  erysipelas,  in  erythema,  and  in  eczema 
erythematosum,  we  see  it  disappear  also  in  lupus  erythematosus.  Pyrogallic  acid  is  of 
the  same  class  of  remedies,  being  one  of  the  phenol  group,  and  till  now  it  has  been 
considered  one  of  the  most  efficient  remedies  in  lupus  erythematosus.  But  the  action  of 
iclithyol  is  much  milder  and  more  effective  than  that  of  pyrogallic  acid. 

Unguent,  diacliyl.  Hebrae  mixes  very  well  with  ichthyol,  and  I use  it  from  three  to 
fifteen  per  cent.  Ten  per  cent,  ichthyol  in  diachylon  ointment  is  a powerful  remedy, 
and  spread  on  a piece  of  cloth  and  applied  affects  the  epidermis,  changing  it  into  a kind 
of  parchment  and  giving  rise  to  blisters  and  suppuration.  After  a few  applications  of 
this  salve  I diminish  the  quantity  of  ichthyol  to  three  per  cent. ; in  this  way  good  epi- 
dermis is  formed,  and  flat  and  scarcely  perceptible  scars  replace  the  spots  of  lupus 
erythematosus. 

In  order  to  finish  the  treatment,  a solution  of  ichthyol  in  collodium  was  used,  to 
brush  once  a day  on  the  place — 

R . Natr.  sulfoichthyol, 

Spirit  aether. , aa  grm.  10.00 

Collodion,  grm.  20.00 

until  the  spots  had  entirely  disappeared  and  the  skin  returned  to  the  normal  condi- 
tion. 

Scarification  can  be  used  while  ichthyol  is  applied,  in  order  to  diminish  the  stasis 
and  facilitate  the  obliteration  of  the  enlarged  blood  vessels. 

DISCUSSION. 

In  the  discussion,  Dr.  Knaggs,  of  England,  asked  if  the  reader  considered  the 
micrococci  as  causative,  and  whether  the  ichthyol  destroyed  them  and  the  tissues, 
too,  or  acted  as  an ' antiseptic. 

Dr.  Ravogli  replied  in  the  affirmative.  The  ichthyol  acted,  he  thought,  by 
abstracting  oxygen,  upon  which  the  life  of  the  cocci  depended. 

Dr.  Unna,  of  Hamburg,  regarded  as  the  most  important  part  of  the  paper  that 
relating  to  microorganisms,  and  he  considered  it  the  weak  point  as  well.  The  cocci 
must  be  seen  in  all  parts  of  the  thickness  of  the  skin,  and,  he  believed,  in  the 
sweat  glands,  too.  He  thought  microorganisms  probably  existed  in  the  disease,  and 
would  some  day  be  discovered,  but  could  not  regard  the  specimens  presented  as 
showing  them,  and  hoped  Dr.  Ravogli  would  continue  his  investigations  and  make 
cultures.  He  asked  if  the  sections  were  made  deep  enough  to  show  the  sweat 
glands. 

Dr.  Ravogli  said  he  had  not  paid  special  attention  to  these  glands. 

Dr.  Unna  was  glad  to  hear  of  the  good  influence  of  ichthyol,  never  having  used, 
it  alone  in  this  disease,  but  with  the  addition  of  salicylic  acid.  He  had  found  resor- 
cin beneficial  and  most  useful  as  a varnish  or  collodion  dressing. 

Dr.  Thin  had  examined  Dr.  Ravogli’ s preparations,  but  was  not  able  to  satisfy 
himself  that  the  minute  particles  he  saw  in  them  were  organisms.  Minute  objects 
in  preparations  of  this  kind  can  only  be  looked  on  as  cocci  if  they  showed  the  char- 
acteristic  staining  by  the  aniline  dyes.  Dr.  Thin  made  some  remarks  regarding  the 
general  nature  of  lupus  erythematosus.  Its  clinical  course  and  pathological  histol- 
ogy are  both  reconcilable  with  the  bacterial  theory,  but  the  bacteria  have  yet  to  be 


SECTION  XIV DERMATOLOGY  AND  SYPHILOGRAPHY. 


205 


shown.  lie  referred  to  some  remarkable  cases  that  had  been  observed  in  London,  in 
which  the  clinical  features  consisted  in  a localized,  raised  eruption,  of  a bright  red 
color,  the  diseased  surface  being  separated  from  the  surrounding  skin  by  a sharp 
line  and  by  the  absence  of  scales  and  crusts  or  secretious.  ‘ ‘ The  cases  had  been  pro- 
fessionally spoken  of  as  the  cocks-comb  disease.”  In  one  of  these  cases  a portion  of 
skin  had  been  excised,  which  Dr.  Thin  had  examined,  and  which  exhibited  the  mor- 
bid anatomy  of  lupus  erythematosus.  The  epidermis  was  raised  and  separated  for 
a considerable  distance  from  the  pars  reticularis  of  the  corium  by  a dense  layer  of 
small  cells,  which  were  intersected  by  blood  vessels  and  which  completely  occupied 
the  place  of  the  pars  papillaris.  In  vertical  sections  the  distance  of  the  lower  bor- 
der of  the  rete  mucosum  from  the  reticular  layer  was  many  times  greater  than  the 
thickness  of  the  papillary  layer. 

Clinically,  the  leading  features  of  the  eruption  were  the  bright  red  color,  the 
remarkable  prominence  and  the  absence  of  secretion  or  desquamation  and  the  strict 
limitation.  Clinically,  experienced  observers  had  found  it  difficult  to  establish  a 
diagnosis. 

Dr.  Klotz  said  he  was  glad  to  hear  Dr.  Ravogli  speak  in  favor  of  milder  appli- 
cations in  preference  to  the  stronger  and  caustic  ones  or  to  surgical  interference,  as 
he  had  come  to  similar  conclusions.  He  had  been  employing  for  the  last  year,  with 
satisfactory  results,  a compound  plaster  of  salicylic  acid  and  soap  plaster. 

The  discovery  of  microorganisms  would  bring  lupus  erythematosus  in  closer 
relationship  again  with  lupus  vulgaris,  from  which  it  had  been  alienated  too  far. 
There  certainly  exist  cases  in  which  it  is  extremely  difficult  to  decide  between  the 
two  forms  of  lupus,  and  where  a combination  of  the  same  seems  to  exist. 

Dr.  Zeisler,  of  Chicago,  thought  the  microorganism  theory  a very  plausible 
one ; still,  it  remains  a theory  as  long  as  pure  cultures  and  successful  inoculations 
have  not  been  demonstrated.  He  wondered  that  reference  had  not  been  made  to  the 
investigations  of  Morrison,  of  Baltimore,  recently  published.  He  mentioned  the 
rare  occurrence  of  lupus  erythematosus  on  mucous  membranes,  of  which  he  had 
lately  observed  a case  in  a lady  from  Wisconsin,  in  whom  the  mouth  was  affected. 
There  were  several  lesions  present  on  the  gums  and  the  mucous  membrane  of  the 
cheeks,  of  a whitish  color  and  scar-like  appearance,  bleeding  very  readily  and  prov- 
ing very  obstinate  to  treatment.  Caustic  nitrate  of  silver  seemed  to  beneficially 
influence  these  spots.  He  agreed  with  Dr.  Unna  as  to  the  value  of  resorcin.  He 
had  found  ichthyol  without  much  value,  while  a ten  per  cent,  solution  of  resorcin  in 
collodion  had  acted  very  well  in  the  above-mentioned  case. 

Dr.  Robinson,  the  President,  spoke  especially  in  regard  to  the  microscopic  speci- 
mens. He  agreed  with  Thin  and  Unna  that  in  all  probability  a microorganism 
exists,  but  he  does  not  think  that  Dr.  Ravogli  has  pursued  proper  methods  in 
his  studies,  nor  do  the  specimens  show  the  bodies  to  be  cocci.  It  is  not  clear  that 
they  are  not  extraneous  matter.  We  must  exercise  great  care  in  placing  importance 

!upon  the  microorganisms  found  upon  the  general  surface.  He  urged  Dr.  Ravogli 
to  follow  up  his  investigations,  and  instead  of  using  caustic  potash,  make  sections 
from  specimens  hardened  in  alcohol  and  stained  in  the  usual  manner  with  aniline 
dyes.  Caustic  potash  he  considered  a veiy  deceptive  agent  to  work  with  when  seek- 
ing for  spores,  as  we  are  likely  to  imagine  their  being  present  when  the  product  is 
only  an  artificial  one,  from  the  agent  employed. 

Id.  closing,  Dr.  Ravogli  said  that  he  labored  under  difficulties  in  making  his  dem- 
onstrations at  this  time.  He  considered  the  test  with  caustic  potash  a convincing 


206 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


one,  as  it  never  attacked  microorganisms,  but  did  attack  everything  else.  He  was 
glad  to  hear  the  opinions  of  so  many  that  microorganisms  probably  existed.  He 
would  not  say  positively  at  the  present  time  that  they  were  causative,  but  would  wait 
until  he  had  been  able  to  make  cultures,  etc. , as  suggested. 


ERYTHEMATOUS  LUPUS  OF  THE  HANDS. 

LE  LUPUS  ERYTHEMATIQUE  DES  MAINS. 

UBER  DEN  LUPUS  ERYTHEMATOSUS  DER  HANDE. 

BY  A.  H.  OHMANN-DUMESNIL,  A.M.,  M.D., 

Of  St.  Louis,  Mo. 

Lupus  erythematosus  (Cazenave),  or  erythematous  lupus,  is  an  affection  which  has 
proven  not  only  interesting  from  a clinical  point  of  view,  hut  has  given  rise  to  much 
discussion  in  regard  to  its  pathology.  Its  clinical  characteristics  and  appearances  have 
been  minutely  described  and  made  thoroughly  familiar;  yet  they  have  not  been  as  care- 
fully elaborated  as  they  might  have  been.  What  I intend  to  convey  is  this:  that  while 
erythematous  lupus  of  the  face  and  head  has  been  often  observed  and  described  in  every 
particular,  and  every  phase  of  its  evolution  noted,  the  invasion  of  other  portions  of  the 
skin  has  either  escaped  attention  or  has  occurred  so  seldom  that  but  few  cases  have  been 
observed,  and  of  these  but  a small  number  have  been  accurately  described. 

That  erythematous  lupus  occurs  most  frequently  upon  the  face  is  fully  proven  by  the 
statistics  of  every  dermatologist,  and  that  its  occurrence  upon  the  trunk  or  extremities 
is  comparatively  unusual  is  also  the  general  experience  of  those  who  have  paid  any 
attention  to  the  subject  of  skin  diseases.  It  is  the  universal  opinion  of  authors  that 
erythematous  lupus  of  the  hands  is  a rare  form  of  the  disease,  and  more  so  when  the 
disease  is  not  to  be  found  upon  any  other  portion  of  the  body.  This  being  the  case,  it 
is  very  strange  that  the  reports  of  such  cases  which  have  been  made  should,  in  a certain 
degree,  be  so  meagre  in  details,  and  I must  urge  this  very  incompleteness  as  an  apology 
for  the  apparently  incomplete  manner  in  which  I have  been  forced  to  tabulate  the  cases 
which  I have  succeeded  in  gathering  together. 

There  is  no  doubt  whatever  in  my  mind  that  these  represent  but  a very  small 
number  of  the  cases  which  have  occurred,  as  many  are  unable  to  recognize  the 
disease,  and  others  observed  it  before  it  had  acquired  a distinct  place  in  nosology ; 
yet  it  must  be  comparatively  infrequent,  when  we  consider  the  number  of  competent 
dermatologists,  and  the  large  amount  of  material  which  passes  through  their  hands  in 
connection  with  the  few  cases  of  erythematous  lupus  seen  by  them,  and  the  extremely 
small  number  of  patients  affected  on  the  hands  by  this  disease.  Of  course,  in  the  ma- 
jority of  cases  there  is  but  little  pain  and  scarcely  any  inconvenience  attending  the 
trouble,  relief  being  most  often  sought  on  account  of  the  appearance  produced.  This 
may  also  be  assigned  as  a reason  for  the  small  number  of  cases  observed. 

On  account  of  these  and  other  reasons  it  has  been  deemed  proper  to  report  somewhat 
fully  a case  of  erythematous  lupus  of  the  hand  and  arm,  which  possesses  some  interest- 
ing features,  more  especially  as  the  report  could  be  made  tolerably  full  by  the  addition 
of  photographs  and  microscopic  preparations  illustrating  the  pathology  of  the  process 
in  this  particular  case.  This  is  done  in  spite  of  the  fact  that  the  case  is  still  under 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPIIY. 


207 


treatment  and  observation.  However,  this  does  not  militate  against  the  clinical  features 
of  the  case  nor  against  a clinical  analysis  of  the  cases  which  I have  collated. 

Case. — W.  C.  C.,  male,  age  fifty-five,  was  referred  to  me  June  3d,  1886,  by  Dr.  F. 
Foster,  of  Memphis,  Mo.  The  history  which  was  furnished  was  as  follows:  The 
patient,  whose  occupation  is  that  of  a carpenter,  is  an  American  and  married.  His 
general  health  has  always  been  good,  and  he  has  never  had  any  other  skin  disease. 
There  is  no  history  of  syphilis.  He  has  always  lived  a regular,  temperate  life.  In 
June,  1882,  he  noticed  a small  macule  upon  the  dorsum  of  his  right  hand.  This 
remained  and  slowly  increased  in  size,  until,  in  the  course  of  a month,  it  had  attained 
the  dimensions  of  a silver  dime,  the  color  being  that  of  a cherry.  He  cut  into  this 
with  his  penknife,  and  from  this  time  on  it  began  spreading  rapidly.  He  was  treated 
by  a number  of  physicians,  who  treated  the  trouble  with  caustics,  using  chiefly  chlor- 
ide of  zinc,  but  with  negative  results.  In  fact,  he  thought  that  the  treatment  greatly 
aggravated  his  trouble.  In  March,  1883,  he  went  to  Hot  Springs,  Ark.,  where  he 
again  went  through  a caustic  treatment  without  any  benefit.  On  July  6th,  1883,  he 
was  seen  by  Dr.  Foster.  The  lesion  then  extended  to  the  entire  dorsum  of  the  hand 
and  up  to  the  second  phalanges  of  the  fingers.  The  Doctor  removed  a portion  with  the 
knife,  for  the  purpose  of  microscopic  examination,  and  was  much  gratified  to  see  the 
wound  heal  kindly.  After  that  time  he  removed  several  large  portions,  this  being 
always  followed  by  “ healthy  granulations.”  The  patient  could  never  be  persuaded  to 
take  chloroform  and  have  the  disease  removed  entire,  but  being  a poor  man  he  con- 
tinued to  work  at  his  trade,  and  only  ceased  doing  so  when  compelled  by  absolute 
necessity. 

June  3d,  1886.  Status  Prsesens.  — The  patient  is  about  five  feet  eight  and  one-half 
inches  in  height,  weighs  about  160  pounds  and  appears  to  be  well  developed  physi- 
cally. His  pilous  system  appears  to  be  well  developed  and  his  skin  is  of  normal  thick- 
ness and  elasticity.  In  color  it  is  normal  on  the  covered  parts,  the  face  and  hands  being 
browned  through  exposure  to  the  sun.  His  hair  is  of  a brown  color.  Upon  no  portion 
of  the  body,  except  the  parts  about  to  be  described,  can  any  affection  of  the  skin  be 
found.  The  part  involved  includes  the  hand  and  forearm  of  the  right  side.  Here  it 
may  be  noted  (see  Plates  I and  n)  that,  in  general,  it  is  the  dorsum  of  the  hand  and 
extensor  surface  of  the  forearm  that  are  implicated.  The  patches  are  distributed  rather 
irregularly,  on  account  of  the  cicatrization  which  has  taken  place.  Upon  careful  exam- 
ination, patches  are  found  distributed  about  as  follows  : one  on  the  dorsal  surface  of  the 
thumb,  involving  the  metacarpal  and  first  phalangeal  surfaces,  and  a smaller  one  on  the 
second  phalangeal  surface,  up  to  the  nail  but  not  implicating  it.  A very  small  patch 
is  found  on  the  first  phalanx  of  the  forefinger  ; another  on  the  first  phalanx  of  the  mid- 
dle finger,  one  on  the  first  phalanx  of  the  ring  finger  and  one  on  the  first  and  second 
phalanges  of  the  little  finger.  An  irregularly  clover-leaf-shaped  patch  involves  the 
metacarpo-phalangeal  joints  of  the  middle  and  ring  fingers  and  extends  up  the  dorsum 
of  the  hand.  Two  or  three  patches  are  located  over  the  carpo -metacarpal  joints,  on  the 
dorsal  aspect,  one  of  the  patches — the  largest — encroaching  upon  the  ulnar  aspect  of  the 
wrist.  A number  of  small  patches  are  irregularly  distributed  over  the  dorsum  of  the 
hand.  About  two  and  one-half  inches  above  the  wrist  joint,  a heart-shaped  patch 
exists,  and  this  is  surrounded  by  cicatricial  tissue.  At  the  junction  of  the  middle  and 
the  upper  third  of  the  forearm,  we  find  an  irregular  horse-shoe-shaped  patch,  which  is 
so  large  that  it  encroaches  upon  both  the  ulnar  and  radial  surfaces  of  the  arm.  Its  con- 
vexity is  directed  upward  and,  in  the  space  included  in  its  curve,  a few  small  patches 
are  to  be  found.  A reference  to  Plates  I and  II  will  show  this  condition  more  clearly,  as 
also  the  comparative  sizes  of  the  patches  and  their  distribution. 

The  sizes  of  the  different  patches  vary  considerably.  Some  of  them  are  about  one- 
fourth  of  an  inch  in  diameter,  and  all  sizes  can  be  found  between  this  and  four  inches 


208 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


by  one,  which  is  approximately  the  dimensions  of  the  largest  one.  The  shapes  of  the 
patches  are  irregular,  although  all  of  them  seem  to  have  a tendency  to  assume  convex 
contours. 

The  patches  have  a somewhat  dark-red  color  inclining  to  a lighter  hue.  On  the 
fully  developed  lesions  may  he  observed  dirty  yellow  crusts,  one  or  two  lines  in  thick- 
ness, and  consisting  chiefly  of  inspissated  sebum.  At  some  points  these  crusts  are 
brownish,  and  everywhere  are  hard  and  stiff.  They  are  pretty  well  defined  against  the 
skin,  and  feel  quite  rough  to  the  touch. 

Between  and  surrounding  some  of  the  patches  are  superficial  cicatrices.  These  are 
especially  pronounced  between  the  highest  patch  and  wrist  joint.  Some  are  to  be  seen 
upon  the  lingers,  and  they  have  the  same  characteristics  as  the  others.  These  cicatrices 
are  nearly  white,  having  a very  slight  pinkish  tinge.  They  are  quite  flexible  and,  to 
the  feel,  communicate  the  sensation  of  a skin  rather  thinner  than  that  of  scar  tissue. 
Upon  close  inspection  it  is  noted  that  small  pits  or  depressions  can  be  found,  irregularly 
distributed,  giving  the  cribriform  appearance  seen  to  accompany  the  cicatrices  which 
are  due  to  the  healing  of  superficial  destructive  processes  of  the  skin.  No  hairs  can  be 
found,  nor  is  there  evidence  of  the  presence  of  sweat  or  of  sebaceous  glands. 

In  regard  to  the  subjective  symptoms  accompanying  this  disease,  the  patient  states 
that  he  has  never  had  occasion  to  complain,  beyond  experiencing  a sharp  pain  at  varied 
intervals.  Sensation  appears  to  be  very  fair  in  the  forearm  and  there  is  apparently  no 
disturbance  of  innervation.  The  patient  protects  the  arm  by  continually  applying  wet 
bandages  over  the  site  of  the  disease  ; and  this  avoidance  of  all  sources  of  external  irri- 
tation may,  in  part,  account  for  his  comparative  immunity  from  pain.  He  complains 
of  pain  on  flexing  the  fingers,  and  says  that  there  is  a diminution  in  the  power  of  the 
hand  when  flexed.  He  is  not  as  strong  as  he  formerly  was  in  that  hand  and  arm. 

With  this  history,  the  diagnosis  was  made  of  erythematous  lupus  and  one  of  the 
smaller  patches  was  excised  for  microscopic  examination.  The  treatment  ordered  was 
as  follows  : To  apply  a paste,  made  of  concentrated  lactic  acid  (Merck’s),  to  which  was 
added  kaolin,  sufficient  to  form  a firm  paste,  to  the  patches,  the  edges  of  which  had 
been  previously  oiled.  As  the  patient  left  for  home  immediately  after  consulting  me, 
Dr.  Foster  carried  out  the  treatment. 

June  18th,  1886.  The  paste  was  applied  and  proved  to  be  exquisitely  painful,  so 
much  so,  indeed,  that  it  was  necessary  to  keep  the  patient  under  the  influence  of  chloro- 
form for  nearly  three  hours,  and  it  was  only  twelve  hours  later  that  he  felt  com- 
fortable. 

June  22d.  A slough  separated,  and  the  case  is  looking  well. 

Aug.  11th.  Dr.  Foster  writes:  “ The  case  is  progressing  finely,  and  is  full  of  promise 
for  the  future.  ” Applications  of  sapo  viridis,  to  be  followed  by  zinc  oxide  ointment, 
were  ordered. 

Aug.  20th.  Dr.  Foster  reported:  “The  case  is  doing  excellently  and  is  nearly 
well.” 

Jan.  16th,  1887.  Nothing  more  was  heard  of  the  case  until  this  date.  Then  I 
received  word  that  the  result  of  the  treatment  was  good  in  its  effects.  The  patient 
wrote  that  the  parts  that  were  not  deep  had  all  sloughed  after  the  application  of  a pvro- 
gallic  acid  ointment,  previously  ordered;  also  that  the  “sores”  looked  smooth  and 
healthy.  He  stated  that  his  general  health  continued  to  be  good. 

Feb.  3d.  The  patient  writes:  “The  ‘ sores  ’ are  pretty  near  the  surface  of  the  skin, 
and  some  of  them  below  it.  They  have  shown  no  disposition  to  heal  up.”  I wrote  to 
him  to  come  and  see  me  soon,  sending  him  at  the  same  time  a stronger  pyrogallic 
ointment.  However,  he  did  not  come,  as  requested. 

Feb.  19th.  Word  received  from  the  patient,  to  the  effect  that  the  “ ‘ sores  ’ do  not 
seem  to  improve  as  they  did  at  first.  Some  parts  are  healing,  while  others  remain  as 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGR APHY. 


209 


they  were.’’  The  condition  seemed  to  be  in  statu  quo,  and  I again  urged  Mr.  C.  to 
come,  in  order  that  I might  see  the  condition  present  and  give  proper  treatment. 

March  10th.  Mr.  C.  writes  that  there  has  been  no  improvement  whatever  for  the 
past  two  weeks.  The  condition  is  about  the  same,  with  the  exception  that  a new  patch 
has  shown  itself  above  the  elbow.  Not  caring  to  do  anything  without  seeing  the  case, 
and  writing  to  that  effect,  I heard  no  more  of  it  for  some  time. 

June  5tli.  I received  a letter  from  the  patient,  informing  me  that  the  hand  had 
become  worse.  The  patch  on  the  arm  was  now  four  inches  in  diameter.  I answered, 
urging  the  man  to  come  and  see  me.  Of  course,  being  a poor  man,  it  is  rather  a hard- 
ship for  him  to  be  compelled  to  travel  such  a distance;  but,  in  justice  to  myself,  I 
could  not  attempt  the  treatment  of  a case  I did  not  see  occasionally.  I am  confident 
that  the  result  would  have  been  much  better  had  the  patient  been  kept  under  observa- 
tion continuously. 

It  is  a well-known  fact  that,  as  a rule,  cases  of  erythematous  lupus  are  essentially 
chronic  and  very  rebellious  to  treatment.  It  is  also  a matter  of  observation  that,  in 
the  majority  of  cases,  the  patients  disappear  before  complete  results  are  attained.  It 
j is  also  a matter  of  record  that  relapses  occur  quite  frequently,  and  it  is  very  difficult  to 
form  just  estimates  of  the  effects  of  treatment.  On  this  account,  I have  refrained  from 
particularizing  or  dilating  on  this  point,  deeming  that  a clinical  analysis  of  cases  and  a 
report  on  the  microscopical  appearances  of  the  case  reported  would  be  of  more  interest. 

Clinical  Analysis. — A search  through  literature,  and  correspondence  held  with  der- 
matologists in  this  country,  has  resulted  in  the  record  of  44  cases  or  45,  including  the 
one  just  described.  Of  these  ten  are  unpublished.  Upon  looking  over  this  list  I find 
that  the  majority  have  one  fault  in  common,  viz. ; the  incompleteness  of  the  record. 
This  is  due  to  a number  of  causes.  One  is  that  some  observers  directed  their  attention 
to  but  a few  points  ; others  did  not  keep  notes  of  the  cases,  at  the  time  they  were  seen; 
and  others  again  kept  but  incomplete  records  or  made  insufficient  reports.  I have  been 
informed  by  some  that  they  could  not  supply  me  with  information,  from  the  fact  that 
they  kept  no  notes  of  any  cases.  Some  may  doubt  that  all  of  the  cases  tabulated  were 
erythematous  lupus;  they  were  reported  to  me  as  such  or  published  as  such,  and  I am, 
perforce,  bound  to  admit  them  as  such  until  they  are  proven  to  be  otherwise. 

In  looking  over  this  table  we  find  that  of  the  24  cases  where  sex  is  specified,  four- 
teen were  females  and  ten  males,  thus  confirming  the  statistics  of  erythematous  lupus 
upon  other  portions  of  the  body.  Where  the  sex  is  not  specified  (in  21  cases)  it  is  very 
probable  that  it  occurred  more  often  in  females.  The  proportion  is  approximately  two 
to  one  in  the  experience  of  all  observers.  In  the  above  cases  it  is  one  and  one-half  to 
one  nearly,  but  the  record  is  not  sufficiently  complete  to  arrive  at  a satisfactory  conclu- 
sion. 

The  earliest  period  of  life  at  which  the  disease  occurred  is  given  as  seven  years  ; 
the  latest,  as  fifty.  The  average  age  is  26.8.  Here  we  must  take  into  consideration  28 
cases  in  which  these  details  are  not  reported.  The  age  at  which  the  reporter  saw  the 
case  is  more  fully  reported,  there  being  but  22  cases  in  which  this  item  is  omitted.  In 
the  remaining  23  cases,  the  youngest  was  seen  at  twelve  years  of  age  ; the  oldest  at 
sixty.  The  average  age  at  which  relief  was  sought  is  32.8.  Taking  the  eighteen  cases 
in  which  the  age  at  which  the  disease  first  made  its  appearance  and  the  age  at  which 
H relief  was  sought  are  given,  we  find  that  the  shortest  time  which  elapsed  between  the 
‘.■I  appearance  of  the  disease  and  its  presentation  to  a competent  observer  is  two  years;  the 

S longest,  fifteen  years.  The  average  duration  is  six  and  one-half  years.  Of  course,  many 
of  these  had  been  seen  and  treated  by  physicians,  and  one  of  the  cases  was  cured  when 
i seen  by  the  observer  who  reports  it  (No.  36).  The  length  of  time  allowed  to  elapse  is 
always  somewhat  considerable,  and  shows  the  comparatively  small  amount  of  annoyance 
* caused  by  the  disease. 

Vol.  IV— 14 


TABLE  OF  CASES  OF  ERYTHEMATOUS  LUPUS  OF  THE  HANDS. 


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212 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  part  first  implicated  is  a matter  of  some  interest.  This  fact  is  reported  in  39 
cases.  In  these,  the  fingers  were  the  portion  first  affected  in  fifteen  cases  ; the  face  in 
twelve,  the  hand  in  eleven  and  the  forearm  in  one.  In  this  last  case  the  arm  was 
exposed,  but  this  seems  to  have  played  no  part  in  the  production  of  the  disease. 

Besides  the  hands  or  fingers,  we  find  that,  in  a number  of  cases,  other  portions  of  the 
skin  were  involved.  In  the  twenty-eight  cases  where  this  involvement  is  noted,  the 
nose  and  face  are  mentioned  most  often.  In  fact,  it  is  only  in  my  case — of  those  where 
other  portions  were  affected — that  it  was  not  some  portion  of  the  face  or  head  that  was 
also  involved.  In  twelve  of  these  cases  the  disease  began  in  the  face  ; so  that,  in  six- 
teen cases,  the  parts  other  than  the  hands  were  invaded  subsequently  to  the  appearance 
of  the  disease  upon  the  hands. 

In  the  entire  list  of  forty-five  cases  specific  information  as  to  the  hands  implicated 
is  given  in  thirty-one;  of  these,  both  hands  suffered  in  fifteen  cases;  the  right  only,  in 
four;  the  left  only,  in  four;  “one  hand”  is  mentioned  in  four  cases,  and  four  are 
unspecified.  Or,  adding  those  specified  distinctly,  we  find  that  in  fifteen  both  hands 
were  involved,  and  in  twelve  one  hand  only,  or  very  nearly  in  equal  proportions.  Six 
males  and  nine  females  had  both  hands  involved;  three  males  and  one  female  had  the 
right  hand,  only,  involved;  and  one  male  and  three  females  had  the  left  hand  only  as 
the  seat  of  the  disease.  The  affection  was  as  severe  on  the  left  hand  of  a right-handed 
individual  as  on  the  right  one  of  another  right-handed  patient.  The  amount  of  use  to 
which  the  hand  is  put  seems  to  exercise  no  influence  upon  the  severity  of  the  involve- 
ment. 

In  thirty-three  of  the  cases  it  is  reported  that  the  fingers  were  involved.  In  all 
those  where  any  details  are  given,  however,  it  is  noted  (as  I did  in  my  case)  that  the 
lesion  never  goes  beyond  the  border  of  the  nail.  The  process  seems  to  stop  short  here, 
and  the  nail  continues  to  grow  in  a normal  manner,  a fact  which  is  confirmatory  of  the 
view  that  the  process  is  a superficial  inflammation,  an  opinion  which  is  also  confirmed 
by  the  appearance  of  the  scars  following  the  lesions  and  by  microscopical  examination. 

The  seat  of  erythematous  lupus  of  the  hand  is  also  a matter  of  some  interest.  The 
dorsal  aspect  of  the  hand  is,  apparently,  the  site  of  predilection.  In  twenty-three  cases 
where  the  location  is  mentioned  the  dorsum  was  the  sole  seat  of  the  disease  in  fifteen 
cases.  In  three  the  palm  alone  was  affected,  and  in  two  both  dorsum  and  palm  were 
implicated.  In  three  cases  the  side  of  the  hand  was  affected,  and  in  one  the  ends  of  the 
fingers. 

In  two  cases  there  were  fissures  observed  in  the  hands,  and  in  one  (No.  28)  the  pulps 
of  the  fingers  were  atrophied,  this  being  probably  due  to  the  fact  that  the  ends  of  the 
fingers  were  affected.  In  several  the  power  of  flexing  the  hand  was  markedly  dimin- 
ished. 

In  regard  to  the  general  condition,  it  may  be  stated  that  while  a number  of  authors 
report  a depraved  general  condition,  others  state  that  their  patients  were  apparently  in 
good  health.  As  this  matter  is  not  fully  dwelt  upon  by  authors  and  reporters,  it  is  not 
possible  to  form  a just  conclusion  on  this  subject.  In  the  case  which  I have  reported 
the  patient  has  always  been  in  a first-class  condition  physically,  and  has  never  com- 
plained of  any  other  affectiou  but  that  of  his  hand  and  arm. 

PATHOLOGICAL  HISTOLOGY. 

Being  engaged  at  the  time  in  microscopic  work,  I requested  my  friend,  Dr.  F.  L. 
James,  of  St.  Louis,  to  examine  the  specimens,  and  the  following  is  his  report : — 

The  material  from  which  the  microscopical  preparations  described  and  figured  herein 
were  made  was  obtained  by  Dr.  Foster,  of  Memphis,  Mo.,  who,  with  a bistoury,  shaved 
off  from  the  affected  surface  three  buttons  or  plaques  of  diseased  skin.  Unfortunately, 
the  plaques  were  put  into  strong  alcohol  at  once,  and  hence  were  considerably  and  per- 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


213 


manently  distorted,  and  still  more  unfortunately,  in  removing  them  in  the  manner 
stated,  I was  furnished  with  none  of  the  surrounding  or  subjacent  tissues,  a study  of 
which  is  absolutely  essential  to  arriving  at  anything  like  a satisfactory  examination  of 
the  morbid  processes  and  appearances  and  a correct  delineation  of  the  pathological 
changes  wrought  in  the  skin  by  the  progress  of  the  disease.  These  facts  are  the  more 
to  be  regretted  as  the  pathological  histology  of  lupus  erythematosus  is  far  from  being 
properly  understood,  as  is  well  known. 

In  a section  of  a plaque  stained  with  osmic  acid  and  lncmatoxylon,  drawn  with  a 
three-quarter-inch  objective  and  two-inch  eyepiece,  giving  an  amplification  of  sixty -five 
diameters  approximately,  the  stratum  corneum  was  almost  entirely  absent.  On  the 
periphery  of  the  plaque  a portion  of  it  is  found.  The  stratum  lucidum,  in  a disinte- 
grated condition  and  separated  from  the  stratum  granulosum  by  layers  of  round-cell 
infiltration,  still  remains  over  a large  portion  of  the  surface. 

When  we  undertake  to  compare  the  balance  of  the  structures  with  the  normal  skin, 
all  is  chaos.  The  invasion  of  the  destroying  agency — the  small,  round  cell,  which  is 
: found  deposited  everywhere  in  countless  numbers — has  totally  altered  and  changed  the 
relationships  of  the  parts.  In  portions  of  the  plaque  the  papillie  can  be  clearly  made 
out,  but  they  are  distorted  into  strange,  fantastic  shapes  and  enormously  enlarged. 
In  other  parts  they  are  entirely  absent  or  their  outlines  have  been  merged,  by  means 
of  infiltrating  deposit,  into  the  surrounding  tissues,  so  that  they  can  no  longer  be  fol- 
lowed. In  some  sections  taken  from  the  centre  of  one  of  the  plaques  the  overlying  layers 
of  the  skin  have  been  destroyed,  and  the  papillae,  enlarged  to  ten  or  even  twenty  times 
their  natural  size,  rise  to  the  very  surface.  In  these  cases  there  are  deposits  of  what 
appears  to  be  effused  blood. 

The  sebaceous  glands  are  distorted  and  swollen  into  almost  unrecognizable  shapes, 
and  are  filled  with  the  ubiquitous  round  cell.  Among  these  round  cells  we  occasionally 
find  nidi  of  very  large  nucleated  and  caudate  cells,  resembling  the  so-called  giant 
cell,  as  also  a few  fat  globules.  At  one  point  we  find  masses  of  caudate  cells  arranged 
in  circles  resembling  somewhat  the  so-called  “ pearls  ” of  epithelioma. 

In  a close  and  prolonged  study  of  the  large  number  of  sections  made  by  me  of  the 
several  plaques  placed  at  my  disposal,  I have  found  the  remains  of  but  one  single  hair. 
It  is  split  and  frayed  and  broken,  and  the  bulb  is  separated  from  its  sheath. 

As  to  the  nature  of  these  destructive  infiltrating  cells,  so  far  as  the  microscope  can 
determine  from  the  specimens  furnished  me,  and  from  which  my  preparations  and  draw- 
ings are  made,  I am  unable  to  discover  that  they  differ  in  any  respect  from  the  embry- 
onic corpuscle  of  the  inflammatory  process. 

As  to  the  method  of  invasion,  it  is  impossible,  from  the  specimens  at  my  disposal, 
to  form  any  theory,  or  to  come  to  any  definite  conclusion,  since  all  parts  of  the  plaques 
;i  seem  equally  invaded.  From  the  greater  destruction,  however,  that  is  apparent  in  the 
< sebaceous  follicles  and  sweat  glands,  it  is  evident  that  these  are  the  earliest  seat  of  the 
invasion.  It  is  in  these  that  we  occasionally  find  masses  of  granular  matter  of  a dirty 
yellow  hue,  and  which  do  not  take  the  stains  applied,  even  osmic  acid  having  no  marked 
I effect  on  them. 

A large  number  of  differential  stainings  with  chloride  of  gold  and  with  osmic  acid 
I failed  to  show  any  trace  of  nerve  terminals  left.  This  fact  probably  accounts  for  the 
fl  total  absence  of  pain  which  the  patient  declared  to  exist  in  the  plaques.  He  also  states 
U that  the  knife,  in  removing  the  plaques,  caused  no  pain. 

It  was  intended,  could  the  patient  have  been  induced  to  allow  the  removal  of  further 
1 material,  to  make  differential  stainings,  in  search  of  specific  microorganisms.  His 
lailure  to  respond  to  our  requests  has,  however,  prevented  the  fulfillment  of  this  design, 

* and  the  work  is  left  for  future  investigation. 


Frank  L.  James. 


214 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  microscopic  appearances  described  above  would  naturally  lead  to  the  same  con- 
clusions that  the  clinical  features  do,  in  a general  sense,  that  the  process  is  essentially 
an  inflammatory  one,  and  that  it  seems  to  be  more  generalized  in  the  epidermic  struc- 
tures, attacking  them  and  the  organs  developed  from  them  in  preference  to  the  deeper 
ones,  the  latter  becoming  but  superficially  implicated.  That  the  correctness  of  the 
views  maintaining  the  position  that  the  process  is  not  essentially  connected  with  the 
sebaceous  glands  is  firmly  based  upon  sound  reasoning  does  not  admit  of  a doubt,  pro- 
vided that  clinical  observation  has  been  accurate;  for  by  referring  to  the  Table,  it  will 
be  found  that  in  five  cases  the  palms  were  alfected  and  in  one  the  ends  of  the  fingers  — 
all  regions  where  no  sebaceous  glands  exist. 

In  conclusion,  I wish  to  acknowledge  valuable  assistance  from  several  papers,  espe- 
cially Dr.  J.  N.  Hyde’s,  on  this  subject,  and  I take  this  occasion  to  extend  my  most 
heartfelt  thanks  to  all  the  gentlemen  who  had  the  kindness  to  answer  my  letters  of 
inquiry  on  this  subject,  for  their  uniform  courtesy. 


DISCUSSION. 

Drs.  Unna,  Hamburg,  Thin,  London,  Klotz,  New  York,  Zeisler,  Chicago, 
Robinson,  New  York,  discussed  the  paper,  and  Dr.  Ohmann-Dumesnil  closed. 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGRAPH Y. 


215 


FOURTH  DAY. 


DAS  SEBORRHOISCHE  EKZEM. 

SEBORRHCEIC  ECZEMA. 

L’ECZEMA  SEBORRHOIQUE. 

VON  P.  G.  IJNNA, 

Hamburg,  Deutschland. 

Es  war  seinerzeit  entschieden  ein  grosses  Verdienst  vom  alteren  Hebra,  eine  Reihe 
von  Krankheitszustandeu  der  Haut,  welcbe  bis  dahiu  vereinzelt  abgehandelt  wurden, 
so  gewisse  Porrigines,  Impetigines  und  squambse  Ausschlage,  als  verscbiedene  Stadien 
I einer  einzigen  Krankheit,  des  chronischen  Ekzeras,  erkannt  und  zusammengefasst  zu 
haben.  In  der  Folge  ist  dann  der  Begriff  des  Ekzems  in  der  von  Hebra  erweiterten 
Gestalt  mit  dem  des  Hautcatarrhs  verschmolzep,  und  wir  sind  gewobnt,  alle  moglicben 
Reizzust'ande  der  Haut,  welcbe  mit  Blaschen,  Jucken  und  Scbuppen  einbergehen  und 
den  Eindruck  einer  oberfliichlicben  Dermatitis  hervorrufen,  heute  Ekzem  zu  nennen. 

Icbglaube,  es  wird  wenige  unbefangene  Dermatologen  geben,  welcbe  diesen  heutigen 
Standpunkt  der  Ekzemlebre  aus  vollem  Herzen  gut  lieissen.  Zuniichst  ist  es  die 
nicht  zu  leugnende  Tbatsaebe,  dass  es  eine  Reihe  wohl  characterisirter  Ekzeme  giebt, 
welche  bei  nocb  so  langem  Bestande  niemals  die  typischen  Formen  des  Blaschens,  der 
rotben  nassenden  Flache  und  scliliesslicb  der  Scbuppen  durchmachen,  sondern  von 
Anfang  bis  zu  Ende  entweder  nur  Papeln  auf  erythematosem  Boden  und  spater 
Schuppen  oder  iiberhaupt  nur  Scbuppen  auf  verdickter,  gerotbeter  Haut  zeigen.  Der 
Praktiker  hilftsich  in  solcben  Fallen  mit  dem  Ausdruck  “ trockenes  Ekzem,”  um  sicb 
dem  Collegen  verst'andlicb  zu  machen,  nicbt  ohne  einen  ironischen  Seitenbieb  auf 
unsere  eigenthiimliche  Nomenclatur,  die  bier  wirklich  an  den  Lucus  a non  lucendo 
erinuert. 

Ich  lege  auf  diese  Contradictio  in  adjecto  keinen  besonderen  Wertb,  denn  sie  ist 
nur  eine  scheinbare.  Beim  1 1 Ekzem  ’ ’ sollte  allerdings  eine  Feucbtigkeit  aussickern  ; 
aber  seitdem  dieser  Begriff  mit  dem  des  Hautcatarrhs  identificirt  ist,  braucht  unser 
Ekzembegriff  nicbt  weniger  und  mehr  zu  sagen,  als  der  des  Catarrhs  iiberhaupt.  Und 
bei  den  Schleimhiiuten  ist  es  bereits  lange  Gebrauch  geworden,  von  einem  trockenen 
1 Catarrh  so  gut  zu  reden,  wie  von  einem  feuchten.  Es  ist  auch  in  der  That  nicbt 
ndtbig,  dass  die  grdssere  Durchfeuchtung  der  Oberhaut,  die  wir  bei  jedem  Catarrh  vor- 
| aussetzen  mussen,  gerade  sichtbarlicb  in  Blaschen,  Pusteln  und  rinnenden  Tropfen  zu 
Tage  tritt. 

Diese  Erweiterung  des  Ekzembegriffes  auf  trockene  Hautcatarrhe  wiirde  ich  an  und 
' fur  sich,  wie  gesagt,  gut  heissen.  Aber  gerade  die  verscbiedenen,  von  Anfang  bis  zu 
Ende  trockenen,  nur  selten  bier  und  da  nassenden  Formen  des  Ekzems  sind  auch  in 
anderen  klinischen  Symptomen  so  eigenartig,  dass  gerade  keiu  besonderer  klinischer 
< Scharfblick  dazu  gebdrt,  bier  wirklich  verschiedene  Krankbeitstypen  auszusondern, 
die  mit  Unrecht  heute  in  die  Olla  potrida,  genannt  chronisches  Ekzem,  zusammen- 
geworfen  werden. 


216 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Von  diesen  trockenen  Formen  ausgehend,  gelang  es  mir  denn  auch  schon  vor  Jahren, 
eine  Reike  wohlcharacterisirter  Ekzemtypen  zunachst  zu  meinem  Privatgebrauch  und 
zu  rascker  Verstiindigung  mit  meineu  Assistenten  und  Zuhdrern  aufzustellen,  und  in 
einigen  neueren  Arbeiten  babe  ich  bereits,  so  kurz  wie  es  die  sonstige  Tendenz  derselben 
gestattete,  einige  derselben  angef  iihrfc.  In  meiner  Privatpraxis  und  Klinik  ist  deshalb 
schon  seit  Jabren  die  einfache  Diagnose  “ chronisches  Ekzem  ” verpont ; ich  begniige 
micb  nicbt  mit  dem  rein  ausserlichen,  bisherigen  Bebelfe  de?  Lehrblicher,  das  chro- 
niscbe  Ekzem  nacb  den  Kbrpergegenden  zu  bezeichnen,  im  Uebrigen  aber  uberall  f'ur 
ein  und  denselben  Krankheitsprocess,  namlich  das  Ekzem,  zu  halten,  sondern  ich 
macbe  es  mir  und  meinen  Assistenten  zur  Pflicht,  nacb  genauer  Untersuchung  und 
Aufnahme  der  Anamnese  die  Diagnose  auf  ein  ganz  bestimmtes  Ekzem.  zu  stellen,  und 
ich  kann  Sie  versichern,  dass  in  wenigen  Mouaten  der  Blick  eines  jeden  Arztes,  der  auf 
die  typiscben  Unterschiede  dieser  Hautcatarrhe  aufmerksam  gemacht  ist,  fur  dieselben 
so  gescliarft  ist,  dass  er  diese  feineren  Diagnosen  uberall  zu  macben  im  Stande  ist. 

Nebmen  wir  z.  B.  das  Gesichtsekzem  eines  Siiuglings,  so  wissen  meine  Schuler  sehr 
wohl,  dass  hier  hauptslichlich  drei  absolut  verschiedene  Typen  zu  unterscheiden  sind  : 
namlich  1)  das  rein  nervose  Dentitionsekzem,  2)  das  tuberkulose  Ekzem  und  3)  das 
seborrhoische.  Wenn  das  Ekzem  nicht  schon  sehr  lange  bestand,  ehe  es  in  Behandlung 
kommt,  so  ist  diese  Unterscheidung  sogar  meist  prima  vista  gemacht.  Eine  Localisation 
an  den  Schleiinhauteing'angen  des  Auges,  der  Nase,  des  Mundes  und  der  Ohren,  eine 
Complication  mit  phlyctanularer  Keratitis,  mit  scrophuloser  Rhinitis,  mit  Otorrhoe, 
ein  grossblasiger  Typus  des  Ekzems  mit  Oedem  und  starker,  verbreiteter  Drlisen- 
schwellung  beifast  fehlendem  Juckreiz,  gharacterisirt  das  tuberkulose  Ekzem,  welches 
Lupus  und  Tuberkulose  prognosticiren  l'asst.  Ist  dagegeu  die  Umgebung  der  Augen. 
der  Nase  und  des  Mundes  frei,  so  dass  das  Ekzem  wie  eine  in  der  Mitte  ausgeschnittene 
Maske  das  Gesicbt  umrahmt,  so  kann  es  sich  entweder  um  ein  Dentitionsekzem  oder 
um  ein  seborrhoiscbes  Ekzem  bandeln.  Das  erstere  tritt  bei  vollkommen  gesuuder 
Haut  meist  in  der  Mitte  der  Backen,  dann  auf  der  Stirn  ganz  symmetrisch  und  fast 
stets  zugleich  auf  der  Radialseite  beider  Handr'ucken  und  der  Handgelenke  auf,  juckt 
ganz  enorm,  um  so  mehr,  je  kraftiger  das  Kind  und  je  gesunder  und  derber  noch  die 
Oberhaut  ist ; es  ist  ganz  abhangig  von  reflectorisch  wirkenden  Reizen  und  speciell 
von  dem  Fortschritt  der  Dentition,  verschwindet  manckmal  nach  dem  Durchbruch 
einiger  Zahne  ebenso  schnell,  wie  es  gekommen  ist,  um  nach  einigen  Tagen  wiederzu- 
kebren  ; es  erinnert  an  Herpes  Zoster,  indem  auch  hier  eine  Gruppe  zunachst  verein- 
zelter,  schon  geformter  Blaschen  auf  gerotheter  Basis  rasch  aufschiessen,  unterscheidet 
sich  aber  durch  die  stricte  Symmetric  und  die  Neigung  zu  fortwahrenden  Recidiven. 

Ganz  anders  das  seborrhoische  Ekzem.  Hier  war  die  Haut  nicht  ganz  gesxmd,  son- 
dem  es  ging  regelmassig  eine,  wenige  Wochen  nach  der  Geburt  auftretende,  oft  gar  nicht 
bemerkte,  aber  stetig  sich  ausbreitende  Seborrhce  des  behaarten  Kopfes  voraus.  Diese 
uberzieht,  oft  erst,  nachdem  sie  einen  niissenden  Character  angenommen,  die  Ohren, 
Stirn  und  Backen,  springt,  ohne  die  Umgebung  der  Augen  zu  beruhren,  auf  die  Augen- 
wimpem  liber  und  breitet  sich  dann  nach  der  Schulter  und  den  Oberarmen  zu  in  meist 
trockenen,  fettigen  Herden  aus.  Dieses  Ekzem  beh'alt  uberall,  auch  an  niissenden 
Stellen,  seinen  fettigen  Character  bei,  juckt  bedeutend  weniger  als  das  Dentitionsekzem, 
aber  doch  mehr  als  das  tuberkuliise,  und  kann  sich  eher  als  die  anderen  beideu 
genannten  Ekzeme  zu  einern  universellen  Ekzem  ausbilden,  indem  es  dann  gewbhulicb 
auf  die  Genitalien  ilberspringt  und  von  hier  aus  Beine  und  R'dcken  uberzieht. 

So  verschieden  wie  der  klinische  Typus,  so  verschieden  ist  die  Behandlung,  und 
deshalb  ist  die  sofortige  richtige  Diagnose  auch  praktisch  von  grossem  Werthe.  Beiui 
nervbsen  Ekzem  ist  die  Aufpinseluug  von  Zinkichthyolleim,  eventuell  als  Maske  mit 
Binden,  anzurathen,  die  das  Kind  nicht  abkratzeu  kann,  daneben  aber  die  geeignete 
Behandlung  des  inneren  Nervenreizes  durch  Bromkalium,  Calomel,  Coca'inbepinselung 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPIIY. 


217 


des  Muudes  u.  s.  f.  Yiel  radicaler  ist  das  tuberkulose  Ekzem  zu  behandeln.  Da  das 
keftige  Juckeu  fortfallt,  ist  eiue  feste  Maske  unnbtbig.  Hier  ist  das  rothe  Quecksilber- 
pracipitat  und  ebenfalls  das  Ichthyol  als  Zusatz  zur  Zinksalbe  vortrefflich.  Beim 
seborrhoiscbeu  Ekzem  hilft  dagegen  in  alien  Fallen  ein  Zusatz  von  Schwefel  zur  Zink- 
salbe,  oder  auck  von  Resorcin,  wiihrend  Icktliyol  kier  nutzlos  ist. 

Ick  miickte  nun  auck  nicktso  missverstanden  werden,  als  wenn  ick  mick  ankeischig 
mackte,  in  jedem  Falle  von  ckronisckem  Ekzem  die  Art  desselben  bestimmen  zu 
kbnueu.  Aber  in  aclit  oder  neun  Fallen  von  zehn  gelingt  dies  dock,  und  die  iibrigen 
sind  solcke,  welcke  sckon  sekr  lange  bestanden  haben  oder  in  welchen  der  kliniscke 
Anblick  und  die  Anamnese  gleichmassig  wakrsckeinlick  macken,  dass  eine  Mischung 
zweier  Ekzeme  vorliegt,  dass  z.  B.  zu  einem  rein  nervbsen  Dentitionsekzem  eines  der 
beiden  anderen,  parasitaren,  Ekzeme  sick  kinzugesellt  hat.  Auck  danu  nock  lasst  sick 
zuweilen  wiihrend  der  Heilung  an  der  Art  der  Wirkung  der  Mittel  oder  an  einem 
friscken  Recidiv  die  genauere  Diagnose  stellen. 

An  diesem  Beispiele,  meine  Herren,  mogen  Sie  erkennen,  dass  man,  okne  das 
kliniscke  Gebiet  zu  verlassen,  genauere  Ekzemdiagnosen  machen  kann  als  die  bisher 
beliebten  Diaguosen  eines  chroniscken  Ekzems  des  Scrotmns,  eines  impetiginbsen 
Ekzems  des  Nackens,  eines  trockenen  Ekzems  der  Arme  u.  s.  f.  Und  zugleich  hat  sich 
diese  Art,  die  Dinge  anzusehen,  fur  die  Praxis  ungemein  bewiikrt  und  den  Blick  fur 
die  versckiedene  Wirkung  unserer  Mittel  sekr  gesch'arft. 

Aber  als  klinische  Diagnosen  bleiben  dieselben  zuniichst  vorldufige , d.  k.  sie  bleiben 
abhangig  von  dem  Zutrauen  der  Fachcollegen  und  dem  praktiscken  Nutzen,  welckeu 
diese  aus  ihrer  Annahme  ziehen.  Zwingende  Beweise  fur  ikre  Existenz  und  eine 
genaue  Abgreuzung  derselben  unter  einander  konnen  erst  erwartet  werden,  wenn  von 
den  parasitaren  Formen  die  Parasiten  sammtlich  rein  gezuchtet  vorliegen  und  von  den 
nervbsen  Formen  die  Abwesenkeit  des  Parasitismus  und  ihre  Abhangigkeit  vom  Nerven- 
system  erwiesen  ist. 

Erst  in  dem  Maasse  und  in  der  Reikenfolge,  als  es  mir  und  Anderen  gelingt,  diese 
den  klinischen  Takt  weit  uberbietenden  objectiven  Beweise  beizubringen,  werde  ick  es 
wagen,  den  Fachcollegen  diese  versckiedenen  Ekzemtypen  detaillirt  vorzulegen,  und 
die  Folgezeit  ward  eben  lekren,  ob  auf  diese  Weise  eine  befriedigende  Eintheilung  der 
Ekzeme  moglick  ist,  ob  diese  rein  klinischen  Unterscheidungen  ricktig  inspirirt  waren. 

In  diesem  Sinne  will  ich  Ihnen,  meine  Herren,  heute  etwas  ausf uhrlicher  die 
klinische  Seite  eines  der  wichtigsten  meiner  Ekzemtypen  vorlegen,  meines  Ekzema 
seborrhoicum. 

Da  dieser  Begriff  fur  mick  schon  lange  an  die  Stelle  des  Begriffes  der  sogenannten 
“trockenen  Seborrhoe  ” getreten  ist,  so  wiirde  ich,  wollte  ick  in  einem  Yortrage  dieses 
Thema  ersckbpfen,  auck  in  eine  historische  Kritik  jenes  auf  sekr  sckwaclien  Grimdlagen 
aufgebauten  Krankheitstypus  eingetreten  kaben.  Es  wiirde  mich  das  viel  zu  weit 
I fiihren,  und  ick  muss  Sie  bitten,  sich  in  dieser  Beziekung  die  im  letzteu  Hefte  meiner 
j Zeitschrift  erschienene  kritische  Uebersickt  : “Was  wissen  wir  ton  der  Seborrhoe  ? ” 
1 anzusehen.  Es  geniigt  fur  den  heutigen  Zweck,  wenn  ick  Iknen  kurz  als  Resultat 
i meiner  diesbeziiglicken  Studien  mittheile,  dass  es  eine  Talgdriisenhypersecretion,  welche 
B sich  klinisch  als  sogenannte  trockene  Seborrhoe  durch  Auflagerungen  festen  Talgdr iisen- 
■'  productes  geltend  machte,  nicht  giebt. 

Was  man  bisher  als  Seborrkoeen  zusammenfasst,  sind  zwei  ganz  verschiedene  Dinge. 
Erstlich  eine  wirklicke,  fettige  Hypersecretion,  die  aber  nicht  von  den  Talgdrusen, 
sondem  von  den  Kndueldrusen  ausgekt.  Diese  Hypersecretion,  die  sogenannte  blige 
1 Seborrhoe,  entleert  sick  durck  die  Schweissporen  nach  Aussen,  ist  also  durchaus  nur  als 
■ eine  Hidrosis  zu  bezeichnen,  und  zwar  als  eine  Hyper  idrosis  oleosa.  Trennen  wir  diese 
vollstiindig  ab,  so  bleibt  die  Gruppe  der  verschiedenen  sogenannten  trockenen  Seborrhceen 
iibrig.  Yon  diesen  nehme  ich  wiederum  die  Form  der  Vernix  caseosa  aus,  welche  eine 


218 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Sonderstellung  einnimmt  und  nur  beim  Fiitus  vorkommt ; sie  ist  das  Product  einer 
echten  Hypersecretion  der  Knliucldriisen,  vermiseht  mit  sich  abschuppenden  Hora- 
lamellen.  Und  icb  nehme  zweitens  vorlliufig  die  sogenannte  Pityriasis  tabescentiuru 
aus,  weil  icli  dieselbe  noch  nicht  microscopisch  untersucht  habe.  Alle  anderen  soge- 
nannten  trockenen  Scborrhceen , welcbe  ich  s'ammtlich  microscopisch  zu  untersuchen 
Gelegenheit  batte,  sind  clironiscli  entzundliche  Processe  der  Haut  und  nichts  weniger  als 
Hypersecretionen  der  Talgdriisen.  Ganz  besonders  gilt  dieses  fiir  die  zur  Alopecie 
f uhrende  Pityriasis  capitis,  die  icb  mit  F.  Hebra  als  identisch  betrachte  mit  der  Sebor- 
rhcea  capitis,  aber  nicht  in  dem  Sinne,  als  wiiren  beide  Talgdr'iisenaffectionen,  sondem 
desbalb,  weil  ich  klinisch  und  histologisch  nachweisen  kann,  dass  beide  nur  verschiedene 
Formen  einer  ganz  bestimmten,  entziindlichen  Hautkrankheit  sind,  welche  vermiige 
einer  Hypersecretion  der  Knaueldriisen  einen  abnormen  Fettreichthum  aufweist.  Dieser 
Fettreicbthum  sitzt  niebt  nur,  wie  man  gemeiniglich  glaubt,  in  denSchuppen,  sondem 
er  durchsetzt  die  gesammte  Lederhaut  und  Oberhaut  wie  bei  keiner  anderen  bisher 
bekannten  Kranklieit.  Die  Lympbbahnen  der  gesammten  Haut  sind  formlich  injicirt 
mit  Fett,  und  die  Production  fettiger  Scbuppen  ist  daher  eine  nothwendige,  nicht 
weiter  iiberraschende  Folge.  Die  Herkunft  dieses  Fettes  kbnnen  nicht  die  Talgdrusen 
sein,  da  dieselben  nach  den  iibereinstimmenden  Resultaten  von  Malassez,  Schuchardt 
und  mir  durchaus  keine  Zeicben  von  Hypertrophie  und  gesteigerter  Thiitigkeit  zeigen, 
vielmebr  durch  abnorm  feste  Hornmassen  vollstandig  verstopft  sind.  Gerade  die  in  die 
Follikel  eintauchenden  Fortsatze  seborrboiseber  Scbuppen,  welche  man  bisher  stet3 
als  Beweis  ansah,  dass  die  fettigen  Schuppen  Product  der  Talgdriisen  seien,  batte  man 
bei  genauerer  Untersucbung  fur  Das  erkennen  miissen,  was  sie  sind,  niimlich  fiir  die, 
die  Follikel  verstopfenden  Hornmassen.  Dieselben  beweisen  nur,  dass  dieselbe  ent- 
ziindliche  Parakeratose,  welche  die  Oberfl'ache  der  Haut  befiillt,  sich  aucb  auf  die 
Haarbalgtrichter,  resp.  den  Talgdriisenausf  iihrungsgang  fortsetzt,  und  sind  der  schla- 
gendste,  microscopisch-kliniscbe  Beweis  fiir  die  mangelnde  Th'atigkeit  der  Talgdriisen. 
Andererseits  wird  dieser  Umstand  aber  aucb  durch  das  Product  der  Scbuppen  bewiesen, 
welches  niemals  Talgdrusenzellen  und  deren  Inhalt  aufweist,  sondem  nur  Hornmassen 
von  dem  Character,  wie  er  alien  entziindlichen  Parakeratosen  und  Catarrhen  der  Haut 
zukommt,  welche  als  specifische  Eigenthiimlichkeit  aber  noch  einen  abnorm  holitn 
Fettgehalt  aufweisen.  Dass  die  wahre  Quelle  dieses  abnormen  Fettgehaltes  in  den 
Knaueldriisen  zu  sucheu  ist,  kann  ich  durch  vier  histologische  Momente  beweisen  : 
durch  die  Identitat  des  Fettes,  welches  die  Cutis,  Oberhaut  und  die  Schuppen  durch- 
setzt mit  dem  Knaueldriisenfett,  durch  die  entzundliche  Veriinderung,. Hypertrophie 
und  die  Zeichen  abnorm  gesteigerter  Th'atigkeit  in  den  Knaueldriisen,  durch  die  Dila- 
tation der  Schweissporen  innerhalb  der  verdickten  Hornmassen  und  durch  die  constante 
Hypertrophie  des  normalen  Kn'aueldriisenproductes  in  der  Tiefe  der  Haut,  niimlich 
des  Fettpolsters. 

Die  genauere  Ausfiihrung  aller  dieser  liier  nur  in  groben  Umrissen  vorgefiihrten 
Punkte  muss  ich  nlir  fiir  eine  grossere  Arbeit  liber  diesen  Gegenstand  aufsparen. 
Ebenfalls  will  ich  bier  nicht  auf  die — noch  nicht  abgeschlossenen — bacteriologischen  Ver- 
suche  eingehen,  welche  den  parasitaren  Character  des  seborrhoischen  Ekzems  erweisen, 
sondern  ich  begniige  mich,  nachdem  ich  so  in  vorliiufiger  Weise  den  Kahmen  dieser 
Krankheit  nach  Aussen  bin  abgesteckt  und  ihr  Verhaltniss  zu  den  bistorisch  verwandten 
Typen  beleuchtet  habe,  mit  einer  kurzen  Schilderung  des  sehr  vielgestaltigen  klinischen 
Bildes. 

Der  Ausgangspunkt  fast  aller  seborrhoischen  Ekzeme  mit  wenigen  Ausnahmen  liegt 
auf  dem  behaarten  Kopfe.  Sehr  selten  beginnt  die  Krankheit  mit  der  entspreehenden 
Affection  des  Augenliderraudes  oder  einer  der  bekauntlich  an  Knaueldriisen  reichen 
Contactstellen  der  Haut  (Achselhiihle,  Ellbeuge,  Cruroscrotalfalte).  Auf  dem  Kopfe 
entsteht  sie  meistens  aus  unmerklichen  Anfangen,  und  erst  eine  pliitzliche  Yerschliui- 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPIIY. 


219 


merung  nach  raonate-  oder  jahrelangem  Bestamle,  eiu  auffiilliger  Haarschwund,  eine 
ungewbhnliche  Schuppen-  oder  Borkenansaminlung,  heftigeres  Jucken  oder  endlich  ein 
umschriebenes  Niissen,  ein  offenbares  Ekzem,  fiihrt  den  Patienten  zum  Arzt.  Die 
Affection  beginnt  also  als  eiu  latenter  Catarrh.  Die  ersten  Spuren  desselben  aussern 
sich  als  ein  lesterer  Zusammenhalt  der  Hornschickt,  die  daher  nicbt  in  insensibler,  son- 
dem  in  sensibler  Weise,  d.  la.  in  grdsseren  Ilorularaellen  abschuppt,  und  weiter  als  eine 
fehlerhafte  Vertheilung  des  Hautfettes,  indem  die  Haare  durch  Verschluss  der  Haar- 
balgtrichter  abnorm  trockeu  werden,  w'ahrend  die  Oberhaut  selbst  und  die  von  ihr 
abschilfernden  Schuppen  (durch  Kniiueldrtisensecret)  abnorm  fettig  sich  anfiihlen. 
Yon  hier  aus  geht  der  Process  in  drei  Eichtungen  auf  deni  Kopfe  selbst  weiter. 
Entweder  die  Sehuppenmassen  vermehren  sich  einfach,  bleiben  aber  stets  weiss  und 
nur  m'assig  fettig  ; allmahlich  gesellt  sich  starkerer  Haarausfall  dazu  und  es  entsteht 
die  bekannte,  characteristische  Glatze  der  Alopecia  pityrodes,  w'ahrend  die  Kopfhaut 
an  den  kahl  werdenden  Stellen  immer  weniger  verschieblich  wird.  Das  Schuppen 
l';isst  wieder  nach,  uni  schliesslich  bei  ausgesprochener  Glatze  ganz  aufzuhbren  und 
: einer  Hyperidrosis  oleosa  Platz  zu  machen. 

In  einer  anderen  Reihe  von  Fallen  nimmt  die  Schuppen  inenge  so  zu,  dass  dieselbe 
i w'ahrend  der  ganzen  Krankheitsdauer  das  Hauptsymptom  darstellt.  Dieselben  liiiufen 
: sich  entweder  als  dicke,  fettige  Borken  zwischen  den  Haaren  an,  welche  der  Haut  mehr 
i oder  minder  fest  adh'ariren,  aber  docli  meist  ohne  Blutung  mit  einer  stumpfen  Kante 
; abzulbsen  sind ; oder  sie  umgeben  bei  vorwiegendem  Befallensein  der  Haarbalgtrichter 
die  austretenden  Haare  mit  Manschetten  aus  Hornsubstanz.  Die  Farbe  der  fettigen 
Borken  variirt  von  weiss  durch  gelb  und  braun  bis  braunschwarz  ; aber  die  dunkle 
Farbe  ist  keineswegs  ein  Product  des  Alters  der  Schuppen  und  der  Unreinlichkeit, 
sondern  sie  ist  in  den  einzelnen  Fiillen  individuell  verschieden  und  dann  im  Verlaufe 
der  ganzen  Krankheit  constant.  Einige  Patienten,  bei  welchen  die  dann  gewbhnlich 
feineren,  fest  anliegenden  Schuppen  die  Farbe  des  Ohrenschmalzes  oder  ein  noch  dunk- 
leres  Braun  zeigen,  beklagen  sich  Uberhaupt  nur  liber  den  vermeintlichen  Schmutz 
auf  dem  Kopfe,  welchen  sie  vergeblich  mit  Seife  zu  entfernen  gesucht  haben.  W'ahrend 
die  erste  Form  meistens  den  ganzen  Kopf  ziemlich  gleichmassig  befallt,  findet  diese 
zweite  sich  meist  an  einigeu  Stellen  des  Kopfes  starker  ausgepr'agt,  so  dass  es  hier  zu 
hervorragenden,  dicken  Borken  kommt,  welche  dann  aucli  auf  einer  m'assig  verdickten, 
hyperamischen  Haut  aufsitzen.  Solche  Pradilectionsstellen  sind  die  Hbhe  der  Scheitel- 
beine  und  die  Hinterhauptsgegend.  Diese  starkere  Form  hat  nun  auch  eine  grosse 
Tendenz,  den  behaarten  Kopf  zu  verlassen  und  sich  liber  die  benachbarten,  mit  Flaum 
bedeckten  Hautstellen  auszubreiten.  Der  erste  Vorstoss  geschieht  gewbhnlich  an  der 
Haargrenze  der  Stirn  und  Sehlafe.  Sofort,  wie  die  Affection  hier  erscheint,  ist  ihr 
Character  auch  viel  deutlicher  ausgepr'agt  als  auf  dem  behaarten  Kopfe.  Sie  schreitet 
hier  mit  einem  scharf  markirten,  fast  stets,  manchmal  sogar  stark  gerbtheten,  mit 
gelben,  fettigen  Schuppen  belegten  Rande  fort  und  umsaumt  die  Haargrenze  guirlanden- 
fbrmig  in  einer  etwa  fingerbreiten  Zone.  Hier  macht  sie  iu  vielen  Fiillen  zunachst 
Halt.  Es  ist  dieselbe  Region,  fur  welche  die  Syphilis  und  die  Acne  varioloformis  die 
i bekannte  Vorliebe  hegt.  Es  giebt  also  auch  eine  Corona  seborrhoica,  die  den  Befallenen 
1 e*netl  sehr  typischen  Anblick  verleiht.  Weiterhin  zielit  sich  die  Affection  gewbhnlich 
an  den  Schliifen,  liber  die  Ohren  nach  dem  Hals  herab,  oder  sie  springt  auf  die  Nase 
■ und  Backen  liber.  Auch  bei  dieser  Form  concurrirt  sehr  hiiufig  ein  betrachtlicher 
| Haarausfall,  jedoch  nicht  mehr  oder  minder  als  bei  der  ersten  Form.  In  beiden  Fiillen 
ist  die  Alopecie  durchaus  nicht  der  Schuppenmenge  proportional,  sondern  lediglich  der 
Straflheit,  mit  welcher  die  Kopfhaut  in  dieser  Krankheit  an  die  Galea  aponeurotica 
angeheftet  wird. 

Die  dritte  Form  ist  diejenige,  bei  welcher  die  catarrhalischen  Ersclieinungen  am 
st'arksteu  ausgesprochen  sind  und  es  zum  N issen  kommt.  Gewbhnlich  ist  es  die  dem 


220 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Ohre  zunachst  gelegene  Partie  der  Schlfifengegend,  in  welcber  sich,  nachdem  eine 
einfacbe  Pityriasis  mit  Jucken,  Spannung  und  Rbthung  vorausgegangen,  das  N'asseu 
einstellt.  Die  fettigen  Scbuppen  werden  abgehoben  und  es  tritt,  wie  immer  beim 
Ekzera,  die  basale,  feucht  glanzende  Homsehicht  dunkelrotb  zu  Tage.  Bei  starkereia 
Niissen  wird  auch  diese  an  einzelnen  Stellen  erodirt,  so  dass  bier  die  Stachelschicht  t'rei 
liegt.  Dabei  geht  die  fettige  Absonderung  fort,  so  dass  die  gebildeten  Krusten  immer 
dick,  brbckelig,  feucht  und  fettig  zugleich  sind.  Fast  immer  werden  bald  auch  die 
Ohren,  wenigstens  die  ilussere  Xante  derselben,  befallen  ; es  tritt,  wie  gewiibnbcb, 
Oedem,  Schwellung  des  ausseren  Gebbrganges  und  die  subjectiven  Beschwerden  liinzu, 
die  jedes  Ohrekzem  begleiten.  W'ahrend  sich  die  niissende  Form  beim  Erwachseuen 
meist  vom  Obr  aus  auf  den  Hals  weiter  ausdehnt,  schreitet  sie  bei  Kindern,  und  beson- 
ders  bei  Siiuglingen,  die  an  Dentitio  difficilis  laboriren,  auf  die  Wangen  und  die  Stirn 
fort,  indem  die  habituelle  Hyperiimie  dieser  Theile  den  Boden  vorbereitet.  Durcbaus 
nicht  immer  verbreitet  sich  das  Niissen  auch  iiber  den  ganzen  behaarten  Kopf ; hiiufig 
bleibt  auf  dem  Mittel-  und  Hinterkopfe  eine  einfache  Pityriasis  oder  Seborrhce  bestehen, 
w'ahrend  Hals  und  Gesicht  das  Aussehen  eines  Ekzema  madidans  bieten. 

Diese  drei  Formen  oder  Grade  des  seborrhoischen  Ekzems  am  Kopfe  entsprechen 
bisher  meist  getrennt  bearbeiteten  Affectionen  der  Autoren.  Die  erste  ist  die  gewbhn- 
liche  Pityriasis  capitis,  die  allm'ahlich  gewdhnlich  zur  Alopecia  pityrodes  fiihrt ; die 
zweite  ist  die  sogenannte  Seborrhcea  sicca  capitis  ; die  dritte  umfasst  eine  grosse  Anzahl 
der  bisher  unter  dem  Sammelbegriffe  des  Ekzema  chronicum  capitis  unterschiedlos 
zusammengefassten  Affectionen,  und  zwar  gehdren  von  den  Ekzemen  der  Kinderkopfe 
nur  ganz  bestimmte,  oben  n'aher  characterisirte  hierher,  von  den  Kopfekzemen  der 
Erwachsenen  jedoch  die  meisten,  besonders  fast  alle  der  besser  situirten  St'ande. 

Indem  wir  das  seborrhoische  Ekzem  jetzt  auf  seiner  Reise  um  den  Korper  begleiten, 
lira  die  ungemein  verschiedenen  Gestalten  zu  bestimmen,  unter  welchen  es  uns  auf  den 
verschiedenen  Hautregionen  entgegentritt,  trennen  wir  innerhalb  jeder  Region  am 
besten  die  genannten  drei  Formen  derselben,  die  ich  zum  Zwecke  rascher  Verstiindigung 
kurz  die  schuppende,  die  borkige  und  die  niissende  nennen  will. 

Vom.  Kopfe  abwarts  gehend,  gelangen  wir  an  den  niichsten  Lieblingsplatz  in  der 
Stemalgegend.  Hier  findet  sich  fast  nur  die  borkige  Form;  viel  selteuer  bei  starker 
Behaarung  die  schuppige  und  noch  seltener  die  niissende,  im  Zusammenhange  mit 
einem  niissenden,  seborrhoischen  Ekzem  der  ganzen  oberen  Korpergegend.  Das  borkige 
Ekzem  dieser  Region  ist  bereits  von  verschiedenen  Autoren  als  eine  besondere  Affection 
beschrieben  worden,  so  neuerdings  noch  von  Colcott  Fox  unter  dem  .Wilson'schen 
Namen  : Lichen  annulatus  serpiginosus,  von  den  Franzosen  als  Ekzema  marginatum. 
Es  sieht  ungemein  characteristisch  aus,  — ich  mbchte  sagen,  es  ist  die  zierlichste  Form 
des  seborrhoischen  Ekzems.  Runde  oder  ovale  Flecken  von  der  Grosse  eines  Finger- 
nagels  stehen  bier  gruppenweise  zusammen,  zum  Tbeil  coalescirend  und  dadurch  zu 
einem  etwa  thalergrossen  Flecke  mit  polycyklischer  Contur  vereinigt.  Der  Eindruck 
einer  vielblatterigen,  geranderten,  bunten  Blume  wird  durch  die  nacb  Aussen  scharf 
abgeschnittenen  Riinder  und  die  Farbenschattirung  hervorgerul’en.  Jeder  einzelue 
Fleck  ist  niimlich  von  gelblicher  Farbe  und  besitzt  nach  Aussen  einen  ganz  feinen, 
rotben  Rand,  wenn  nach  dem  Reinigen  das  feine  Sehfippchen  dieses  Randes  entfenit 
ist.  Dieses  ist  die  gewiihnlichste  Form  unserer  Affection  in  der  Stemalgegend  bei 
geringer  Entwickelung.  Man  findet  sie  bfter  dort,  wo  fiber  dem  Sternum  etwas  Fett- 
polster  entwickelt  ist  und  langere  Haare  producirt  werden,  als  wo  die  Haut  sebr  zart, 
dfinn  und  haarlos  ist.  Nimint  die  Affection  hier  griissere  Dimensionen  an,  so  ist  die 
ursprfingliclie  Stiitte  in  ein  gelb  gefiirbtes,  ziemlich  glattes,  nur  massig  schilfemdes 
Centrum  verwandelt,  an  dessen  Peripherie,  zum  Tbeil  unregelmiissig  zerstreut,  zum 
Tbeil  zusammenhangend,  aber  immer  in  Form  convex  nach  Aussen  gerichteter  Bogeu- 
linien,  sich  frische  Eruptionen  linden,  die  den  Character  des  ursprfingliehen  Herdes 


SECTION  XIV — DERMATOLOGY  AND  SYrHILOGRAPHY. 


221 


besitzen,  also  eine  rothe,  papulose  Erliebung  darstellen,  bedeckt  rnit  gelblichweissen 
oder  gauz  gelben,  brockeligen,  fettigeu  Scbuppen.  Diese  letztere  Form  lindet  sich  auch 
meist  auf  dem  R'ticken  iu  der  Iuterscapulargegend,  der  Schweissrinne  des  Rliekeus. 

Wieder  etwas  auders  sehen  die  Flecke  iu  deu  Achselhdhleu  aus,  wo  sie  sich  nebenbei 
durcb  starkeres  Juckeu  auszeicbneu.  Schuppen  und  Borlcen  siud  bier  fast  nie  zu  seheu, 
souderu  uur  eiue  rothe,  serpigines  fortschreitende,  feiue  Bogeulinie.  Auch  die  gelbe 
Farbe  des  Centrums  hebt  sieli  bier  kaum  ab.  Diese  ubrigens  seltenere  Localisatiou 
zeigt  mancbmal  eine  Steigerung  zur  nassenden  Form,  wobei  sich  dann  das  Ekzem 
gewdhnlich  rasch  liber  den  Thorax  verbreitet. 

Von  der  Schultergegend  steigt  das  seborrhoische  Ekzem  — fast  immer  in  der  borki- 
gen,  selten  der  nlissenden  Form  — auf  die  Arme  herunter.  Auch  liier  zeigt  es  eine 
besondere  Vorliebe  zu  den  Beugeseiten,  obwohl  es  die  Streckseiten  nicht  verschont. 
Aber  — im  stricten  Gegensatze  zur  Psoriasis  — bildet  der  Ellbogen  durchaus  keine 
Prlidilectionsstelle.  Gewdhnlich  ist  er  sogar  ganz  frei  ; nur  bei  universeller  Ausbrei- 
tung  wird  er,  immer  erst  secundar,  mitbefallen.  Diese  Vorliebe  fur  die  Beugeseiten 
und  Contactstellen  erklart  sich  aus  der  Rolle,  welche  die  Kn'aueldrilsen  beim  Ekzema 
seborrhoicum  spielen. 

Die  Handrlicken  sind  wieder  ein  Lieblingssitz  der  nassenden  Form,  besonders  die 
Ruckseiten  der  Finger.  Es  ist  eine  ungemein  hliufige  Combination,  dass  von  einem 
borkigen,  seborrhoischen  Ekzem  des  Kopfes  ein  nlissendes  der  Ohren  und  des  Gesichtes 
und  dann  sofort  mit  Ueberspringung  des  Rumpfes  und  der  Arme  ein  nlissendes  Ekzem 
des  Hand-  und  Fingerriickens  ausgeht.  Sehr  selten  zeigen  Arme  und  Hiinde  das  einfach 
schuppige  Ekzem  in  der  Form  flacher,  gelblicher,  juckender  und  schuppender  Flecke. 
Ganz  besondere  Gestalt  nimmt  dagegen  wieder  die  Affection  an  den  Handtellern  und 
Fusssohlen  an,  wenn  sie  bier  sich  — wie  es  allerdings  selten  vorkommt  — localisirt. 
Dass  sie  bier  liberhaupt  auftritt,  ist  allein  schon  ein  stricter  Beweis,  dass  sie  von  den 
Talgdriisen  ganz  unabhangig  ist.  Anstatt  zusammenhlingender  Flachen  und  serpigi- 
ndser  Kreise  finden  wir  hier  einzelnen  Knliueldr  iisen  entsprechende,  erbsen-  bis  kirschen- 
grosse  Schuppenkiigelchen,  welche  einer  Psoriasis  guttata  lihnlich  sehen.  Bei  der 
Abheilung  dieser  Stellen,  die  ungemein  langsam  vor  sich  geht,  schilfert  die  Hornschicht 
in  grdsserem  Umfange  ab  und  die  Hand-  und  Sohlenfl'ache  nimmt  ein  landkartenartiges 
Aussehen  an.  Hier  kommt  es  niemals  zum  Nassen.  Ich  habe  diese  Localisation  ganz 
isolirt  mit  der  schuppigen  und  borkigen  Form  des  behaarten  Kopfes  und  wenigen 
Stellen  am  iibrigen  Kdrper  gesehen,  wie  andererseits  bei  universellem  Ekzema  sebor- 
rhoicum des  Korpers  vom  Scheitel  bis  zur  Sohle. 

Am  unteren  Theile  des  Rumpfes,  auf  dem  Ges'asse  und  den  Hiiften  sehen  wir 
meistens  allein  die  borkige  Form,  in  Ringen  und  Gyris  serpiginds  fortschreitend,  mit 
Hinterlassung  gelblicher  Flecke.  In  der  Analgegend  findet  sich  wieder  die  zierlichere 
Gestalt  der  Kreise  und  Ringe,  wie  wir  sie  vom  Sternum  und  der  Axilla  her  kennen. 
Die  Cruroscrotalfalte  und  die  anliegende  Partie  der  Oberschenltel  und  des  Hodensackes 
ist  dagegen  ein  Lieblingssitz  der  groberen,  borkigen  Ringe,  und  stellt  daher  eine  nicht 
seltene  Art  des  sogenannten  Ekzema  marginatum  Hebra  dar,  worunter  gewiss  eine 
ganze  Reihe  verschiedener  Pilzkrankheiten  heutzutage  zusammengeworfen  wird.  Am 
Hodensack  geht  die  borkige  Form  bei  langerem  Bestande  so  gut  wie  regelmlissig  in  die 

Inlissende  iiber.  Die  Oberschenkel  sind,  wie  auch  der  untere  Theil  des  Rumpfes,  seltener 
Sitz  der  Erkrankung  und  participiren  nur  bei  universellerer  Ausbreitung  mit  einigen 
Flecken.  Ebenso  wenig  bilden  die  Streckseiten  der  Kniee  einen  Anziehungspuukt  f Ur 
unser  Ekzem.  Dagegen  kommt  es  wieder  haufiger  vor  in  den  Kniebeugen  und  vor- 
zuglich  am  Unterschenkel.  Hier  finden  wir  im  Beginne  der  Affection  stets  nur  die 
■ grosspapulijse,  grobborkige  Form,  welche  hier  aber  mehr  Platten  und  miinzenfdrmige 
Flecke  als  Ringe  bildet ; bei  llingerem  Bestande  pflegt  jedoch  die  nlissende  Form  nicht 
auszubleiben,  besonders  bei  der  Complication  mit  Varicen.  Sehr  selten  finden  sich 


222 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


vereinzelte  Flecke  am  Fussriicken.  Die  Fusssohlen  leiden  nur  gleichzeitig  mit  den 
Ilandtellern  und  in  vdllig  analoger  Weise. 

Mit  Willen  habe  ich  die  Beschreibung  des  seborrhoischen  Ekzems  im  Gesicht  bis 
zuletzt  aufgespart,  nachdem  wir  die  Hauptformen  am  KiJrper  haben  Revue  passiren 
lassen;  denn  hier  finden  sich  noch  einige  ganz  besondere  Eigenth'umlichkeiten.  Die 
schuppige  Form  tritt  bei  Vorhandensein  eines  Bartes  als  diffuse  Pityriasis  einerseits, 
andererseits  aber  auch  als  umschriebene,  etwas  gerdthete,  starker  juckende  Flecke  ira 
Schnurr-  und  Backenbart  auf.  Haarausfall  folgt  hier  nie,  auch  bei  noch  so  langem 
Bestaude,  da  die  straffe  Anheftung  der  Cutis  hier  ja  fehlt.  Bei  Frauen  ist  die  diffus 
schuppige  Form  selten,  kommt  aber  hin  und  wieder  vor  in  Form  einer  feinen  Abschil- 
ferung  und  leicht  gelblichen  Yerfarbung  der  Stirn  und  seitlichen  Wangenpartieen. 
Meist  finden  wir  hier  umschriebene,  schuppige,  gelbliche  Oder  graugelbliche,  leicht 
erhabene  Flecke,  welche  oft  nur  bei  guter,  seitlicher  Beleuchtung  sichtbar  sind  und  von 
den  Patientinnen  meist  selbst  libersehen  werden,  obgleich  sie  an  diesen  Stellen  hin  und 
wieder  Jucken  zu  haben  angeben.  Diese  Flecke  occupiren  meist  die  Stirn,  die  Backen, 
bis  zur  Nasolabialfurche  und  ziehen  sich  von  dort  auf  die  seitlichen  Theile  des  Halses 
herab. 

Haufig  begegnen  wir  einer  starker  entziindlichen  Form  des  seborrhoischen  Ekzems 
im  Gesichte,  und  dies  fast  regelmassig  da,  wo,  wie  im  Klimacterium,  Blutwallungen 
nach  dem  Gesichte  stattzufinden  pflegen.  Hier  siedelt  sich  im  Gefolge  einer  jeden 
st'arkeren  Erhitzung  eine  grosse  Anzahl  feiner  und  griisserer  rother  Papeln  auf  Stirn, 
Nase  und  Wangen  an.  Die  kleinsten  sind  von  der  Grosse  eines  Senfkornes  und  rund, 
die  grosseren  etwa  erbsengross  und  mit  zackigen,  unregelmassigen  Auslaufem  verseben. 
Diese  rothen  Papeln  sind  schuppenlos  oder  mit  feinen,  gelblichen  Schuppen  versehen, 
je  nachdem  Waschungen  vorgenommen  oder  gemieden  werden.  Zwischen  den  Papeln 
Tbthet  sich  die  Haut  und  es  besteht  ein  bestandiges,  leises  Brennen  in  dieser  mittleren 
Partie  des  Gesichtes.  Allmahlich  entwickelt  sich,  wenn  nicht  kiinstlich  Heilung 
herbeigef'uhrt  wird,  aus  diesen  Anfiingen  eine  regelrechte  Rosacea,  und  zwar  die  von 
mir  als  ekzematos  bezeichnete  Form.  Das  Ekzema  seborrhoicam  ist  bei  den  Frauen  ei  ie 
■der  hdufigsten  Ursachen  der  Rosacea  uberhaupt,  und  viele  F'alle  von  Rosacea  bessern  sich 
sofort,  sowie  das  verursachende  Ekzema  seborrhoicum  des  behaarten  Kopfes  geheilt 
wird . Uebrigens  ist  auch  bei  M'annem  haufig  der  Alkoholgenuss  nur  die  disponirende, 
entferntere,  ein  iibersehenes  Ekzema  seborrhoicum  des  Kopfes  die  n'aliere,  directe 
Ursache  der  Rosacea. 

Ungemein  selten  bei  jiingeren  Leuten  ist  die  grobborkige  Form  im  Gesichte.  Dort 
kommt  sie  als  ein  fettig  brockeliger,  schwer  abzuhebender,  gelber,  brauner,  ohren- 
schmalz'ahnlicher  Belag  auf  umschriebenen  Stellen  der  Wangen,  Nase  und  Stirn  vor 
und  ist  mit  ziehenden  Schmerzen  in  diesen  Theilen  verbuuden.  Viel  haufiger  und  in 
schmerzloser,  schleichender  Weise  entstehen  solche  seborrhoischen  Flecke  bei  alten 
Leuten  um  Mund  und  Nase  herum  und  geben  bekanntlich  den  Ausgangspunkt  fiir 
■Carcinome  (Volkmann’s  seborrhagische  Carcinome)  her. 

Endlich  neigt  das  Gesicht  auch  zur  nassenden  Form  des  Ekzema  seborrhoicum,  uud 
zwar  besonders,  wie  wir  schon  gesehen  haben,  bei  Kindern,  sehr  viel  seltener  bei 
Erwachsenen,  und  hier  wohl  nur  im  Zusammenhange  mit  einem  n'asseuden  Ekzem  des 
ganzen  Kopfes  und  Halses.  Das  Jucken  bei  diesem  Ekzem  ist  unbedeutend  ; Bliiscben 
sind  nie  vorhanden,  sonderu  nach  Abhebung  der  fettigen  Borken  ist  sofort  das  Ekzema 
rubrum  etablirt,  welches  durch  das  schuppende  Stadium  wie  gewbhnlich  abheilt.  Bei 
intercurrenten  Verschlimmerungen  des  Ekzems  treten  auf  der  n'asseuden  Flache  Schiibe 
von  zuerst  stark  juckenden,  frischen  Papeln  auf.  Auch  bei  starkerer  Ausbilduug  dieser 
Form  bleibt  Nase  und  Mund  vom  Niissen  fast  immer  verschont. 

Es  erlibrigt  noch  ein  Wort  liber  das  seborrhoische  Ekzem  der  Angenlider  und  des 
Gehbrganges.  In  den  Meibohm’schen  Driisen  etablirt  sich  dieses  Ekzem  so  gut,  wie 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPIIY. 


223 


in  den  Knliueldriisen  und  ist  von  besonderer  Hartn'ackigkeit.  Gerade  diese  Localisation 
bildet  beiru  Mangel  jeglicker  Affection  des  behaarten  Kopfes  den  Ansgangspunkt  eines 
sicb  vreiter  verbreitenden  Ekzema  seborrhoicum.  In  den  meisten  Fallen  istaber  scbon 
vorber  die  Affection  am  Kopfe  aufgetreten,  und  es  ware  stets  wicbtig,  f iir  den  Hausarzt 
sowobl,  wie  fur  den  Augenarzt,  diese  Quelle  der  Augenaffection  zu  kennen,  da  okue 
ibre  Beriicksicktiguug  eine  dauernde  Heilung  der  Augenaffection  nicht  zu  erzielen  ist. 
Die  Borken  bei  dieser  Ekzemform  der  Augenlider  sind  trocken  fettig  ; nur  selten  kommt 
es  zum  Schwund  der  Cilien,  welcbe  sicb  allerdings  rascher  b'aren.  Hiiufig  bestebt  eine 
concomitirende,  durcb  die  Lidaffection  unterhaltene  Couj  unctiritis  chronica  palpebrarum. 

Im  Gehdrgange  kommen  alle  drei  Formen  vor.  Bei  irgendwie  erheblichem  Ekzema 
seborrhoicum  des  Kopies  bestebt  fast  immer  ein  einfaches  Scliuppen  des  Gehiirganges, 
welches  mit  Trockenheit  und  Jucken  einhergeht.  Regelmiissig  ist  eine  abundante, 
feste  Absonderung  der  Knliueldriisen  des  Gebbrganges,  d.  i.  der  Ohrenschmalzdr'iisen. 
dabei  vorhanden.  Die  borkige,  seltenere  Form  geht  gewohnlich  bald  in  die  niissende 
iiber.  Die  Niigel  werden  nur  selten  vom  seborrhoischen  Ekzem  befallen  und  zeigen 
dann  eine  von  vorne  nach  hinten  schreitende,  die  Nagelplatte  abbebende  Hyperkeratose 
des  Nagelbettes,  wie  andere  Pilzkrankheiten. 

Wenn  ich  nun  noch  erwiihne,  dass  an  behaarten  Stellen,  vorziiglich  auf  dem  Kopfe, 
das  seborrhoische  Ekzem  hin  und  wieder  Veranlassung  zur  Production  richtiger,  spitzer 
Warzen,  spitzer  Condylome  giebt,  so  habe  ic.h,  so  kurz  wie  moglich,  die  ungemein  ver- 
I schiedenartigen  Krankheitsbilder  dieser  einen,  hochst  versatilen  Affection  vorgef  iihrt, 
und  wende  mich  nun  zum  ganzen  Habitus,  zum  Verlaufe  der  Krankheit. 

Das  Ekzema  seborrhoicum  schreitet  stets  langsam  peripherisch  weiter,  nachdem  es 
. am  Orte  seines  Ursprunges  oft  Jahre  lang  unter  geringen  Symptomen  bestanden  hat. 

Da  dieser  Ort  meist  der  behaarte  Kopf  ist,  so  resultirt  daraus  in  weitaus  den  meisten 
i Fallen  ein  Gang  der  Krankheit  von  oben  nach  unten,  vom  Kopfe  liber  die  Ohren  und 
das  Gesicht  abwiirts  zum  Halse,  von  hier  nach  dem  Sternum  und  der  Interscapularrinne 
und  an  den  Armen  hinunter.  Auch  die  rascher  sich  ausbreitenden  Falle  bleiben  hier 
lange  stehen,  und  diese  Aussaat  der  Krankheit  vor  oben  nach  unten  mit  Bevorzugung 
der  genannten  Punkte  der  oberen  Korperhiilfte  ist  so  characteristisch,  dass  sie  f iir  das 
Ekzema  seborrhoicum  geradezu  als  pathognomonisch  gelten  kann.  Kein  anderes  Ekzem 
und  keine  Psoriasis  halt  diesen  Gang  ein.  Unter  abwechselnden  spoutanen  und  kiinst- 
lich  herbeigefiihrten  Remissionen  breitet  sie  sich  dann  langsam,  mit  sichtlicher  Ver- 
meidung  der  fur  Psoriasis  so  characteristischen  Kniegegend,  nach  unten  weiter  aus. 
Meistens  bleiben  grossere  Hautstrecken  von  der  Affection  frei,  so  dass  bei  der  Neigung 
derselben  zur  Scheiben-  und  Ringform  ein  sehr  buntscheckiges  Aussehen  entsteht. 
Dieses  hbrt  erst  wieder  auf  in  jenen  seltenen  Fiillen,  wo  nach  Jahre  langem  Bestande 
buchstiiblich  der  ganze  Kbrper  iiberzogen  wird.  Dann  erinnert  die  Affection  an  eine 
Pityriasis  rubra,  unterscheidet  sich  aber  — ausser  durch  den  verschiedenen  Geruch  — 
auf  den  ersten  Blick  durch  die  Dicke,  die  gelbe  Farbe,  die  Brbckeligkeit  und  Fettigkeit 
der  Schuppen,  weiterhin  auch  durch  ihre  Benignitat. 

Denn  selbst  in  diesen  Fallen  ist  das  Allgemeinbefinden  nicht  mehr  gestort  als  bei 
universellen  Ekzemen  iiberhaupt,  und  sie  enden  bei  zweckmiissiger  Behaudlung  nach 
noch  so  langem  Bestande  regelmiissig  in  Genesung.  Das  Ekzema  seborrhoicum  ist  auch 
- dadurch  gutartig,  dass  es  relativ  wenig  juckende  Empfinduugen  hervorruft.  Bei  der 

1 schuppenden  und  borkigen  Form  spiiren  die  Patienten  eigentlich  nur  Jucken  und  hin 
| und  wieder  auch  Schmerzen  an  der  Peripherie  der  Flecke,  so  lange  dieselben  fortschrei- 
i ten,  bei  der  nassenden  Form  fast  nur,  wo  frische  Papeln  aufschiessen.  Die  Lymph- 

driisen  sind  nicht  nothwendig  intumescirt.  Ich  halte  es  sogar  f iir  miiglich,  dass  ihre 
( Sehwellung  die  Folge  von  Secundarinfectionen  sind,  da  ich  immer  nur  die  Nackendriisen 
und  die  Inguinaldr'iisen  geschwollen  fand  und  die  Intumescenz  iiberhaupt  hiiufig 

2 vermisste. 


224 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Far  die  Differentialdiagnose  kommen  hauptsiichlich  andere  chronische  Ekzeme  und 
die  Psoriasis  iu  Betracht.  Eiu  niissendes  chronisches  Ekzem  irgend  welcker  Provenienz 
ist  vou  dem  niissenden,  seborrhoischea  Ekzem  nicht  anders  mit  Sicherheit  zu  unter- 
scheiden,  als  durch  die  characteristisclien,  schuppenden  und  borkigen  Sckeiben  an  der 
Peripherie  und  durch  die  seborrhoische  Ursprungsstiitte,  resp.  den  Gang  der  Affection; 
denn  die  besten  Characteristica,  die  fettigen  Borken,  die  Configuration  der  Scheiben 
uud  Kreise,  f'allt  dauu  ja  fort.  Fur  die  richtige  Behandlung  ist  diese  Erkenntniss 
aber  sehr  wichtig.  Typische  Fiille  von  universellem,  borkigem  Ekzema  seborrhoicum 
vou  universellen  Psoriatiden  zu  unterscheiden,  ist  nicht  schwer.  Aber  doch  treten 
manchmal  bedeutende  Schwierigkeiten  auf,  besonders  bei  der  Differenziirung  beider 
Krankheiten  auf  den  unteren  Extremitiiten  in  alten  Fallen.  Diese  Schwierigkeiten 
werden  auch  bestehen  bleiben,  weun  die  Kenntniss  des  seborrhoischen  Ekzems  eine 
allgemeine  geworden  ist.  Bis  jetzt  liegt  die  Sache  freilich  anders,  und  man  kann 
sagen,  dass  geradezu  fast  alle  Fiille  von  universellem,  borkigem  Ekzema  seborrhoicum 
uuter  der  falschen  Etiquette  “ Psoriasis  ” umhergehen  und  geheilt  werden.  Ich  stfitze 
dieses  Urtheil  nicht  auf  die  Diagnosen  von  Hausiirzten,  sondern  ich  habe  in  meiner 
Klinik  Gelegenheit  gehabt,  Patienten  an  dieser  Krankheit  zu  behandeln,  bei  denen 
frfiher  die  Diagnosis:  Psoriasis  von  Fachcollegen  gestellt  wurde,  die  ich  selbst  als  Meister 
in  unserer  Kunst  verehre.  Ich  kann  deshalb  auch  nebenbei  bezeugen,  dass  diese  Affec- 
tion ebensogut  in  Russland,  Skandinavien,  England,  Holland,  Frankreich  und  Nord- 
ainerika  bleibt,  wie  in  Deutschland.  Ich  glaube  mich  daher  nicht  zu  irren,  wenn  ich 
sage,  dass  bei  griindlicher  Kenntnissnahme  des  Ekzema  seborrhoicum  nicht  nur  ein 
Theil  der  Ekzeme  genauer  erkannt  und  rascher  geheilt,  sondern  auch  ein  grosser  Theil 
psoriasis-ahnlicher  Exantheme  von  der  echten  Psoriasis  abgetrennt  werden  und  einer 
gunstigeren  Beurtheilung  unterliegen  wird. 

Deshalb  ist  die  Differentialdiagnose  zwischen  unserem  Leiden  und  der  Psoriasis  so 
wichtig.  Ausser  verschiedenen  geringf  iigigen  Momenten  sind  hier  vor  Allem  stets  die 
vier  Hauptpunkte  eingehend  zu  beriicksichtigen.  Erstens : der  Gang  unseres  Ekzems 
von  oben  nach  unten,  meist  in  der  Mitte  des  Kbrpers  stationiir  bleibend,  bei  der  Pso- 
riasis die  Ausbreitung  von  Ellbogen  und  Knieen  aus  in  mehr  plotzlicher  Weise  fiber 
den  ganzen  Kbrper.  Ziveitens : die  nie  fehlende  Vorgeschichte  einer  oft  heimlich  und 
ganz  unbekannt  verlaufenen  seborrhoischen  Localaffection.  Drittens : der  nie  fehlende 
Factor  der  Fettbeimischung,  der  sich  in  zwei  Momenten  ausspricht  — in  dem  bekannten, 
fettig  brbckeligen  Character  der  Schuppen  und  in  der  gelblichen  Farbe  der  ganzen 
Affection.  Viertens : die  eigenthfimliche  Configuration  der  Einzelefflorescenz  im  Fort- 
schreiten  derart,  dass  die  dicken  Scheiben  spontan  in  der  Mitte  oder  nach  einer  Seite 
hin  sich  abflachen,  ihr  Roth  sich  in  Gelb,  die  schuppige  Oberfliiche  sich  in  eine  glatte 
verwandelt,  um  plotzlich  am  Rande  wieder  in  einen  erhabeneu,  rothen,  schuppen- 
belegten,  bogenfbrmigen  Wall  fiberzugehen.  Deshalb  ist  nun  die  Differentialdiagnose 
an  den  Unterschenkeln  gerade  so  schwierig,  weil  hier  sehr  oft  die  Scheiben  in  der  Mitte 
nicht  einsinken  und  das  cyanotische  Blau  aller  Unterschenkelaffectionen  das  specifische 
Gelb  der  Affection  compensirt.  Man  stelle  also  seine  Diagnose  nach  den  Efiiorescenzen 
des  Oberkbrpers. 

Aus  diesen  differentialdiaguostischen  Bemerkuugen  geht  hervor,  dass  die  genaue 
Diagnose  hier  auch  fur  die  Prognose  und  Therapie  eine  grosse  Bedeutung  besitzeu  muss. 
Und  in  der  That  ist  die  Prognose  des  seborrhoischen  Ekzems  wesentlich  gfinstiger  als 
die  der  Psoriasis.  Wir  kennen  eben  die  Ursprungsstiitte,  und  diese  ist  unseren  localen 
Mitteln  leicht  zuganglich.  Wenn  daher  ein  noch  so  schlimmes,  seborrhoisches  Ekzem 
geheilt  ist,  so  haben  wir  in  der  Pflege  des  Haarbodens,  oder  eventuell  der  Augenlider, 
eiu  sicheres  Vorbeugungsmittel  gegen  einen  Rfickfall  der  Erkrankung  der  Ubrigen  Haut. 
Schon  oft  war  es  mir  mbglich,  auf  diesem  Wege  die  Prognose  einer  bis  dahin  l fir 
Psoriasis  und  fur  unheilbar  gehaltenen  Hautkrankheit  in  eine  absolut  gute  urnzu* 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


225 


gestalten.  Wo  iramer  mail  bei  eiuer  uuiversellen  Psoriasis  Kniee  und  Ellbogen  relativ 
oder  ganz  frei,  die  Sehuppea  gelblicli  fettig  fiudet,  da  sollte  man  sol'ort  Verdacht  auf 
cine  niebt  richtige  Diagnose  schiipfen  uud  instinctiv  mit  Auge  und  Hand  den  Haarboden 
uutersucben. 

Damit  ist  aber  niebt  gesagt,  dass  die  Heilung  des  seborrhoischen  Ekzems  immer 
eine  leichte  Saehe  sei.  Sie  ist  es  schon  desbalb  nieht,  weil  bei  ihr  wesentlich  die  tief- 
liegenden  Knaueldrusen  ergriffen  sind,  uud  verlaugt  oft  grosse  Consequenz.  Aber  wir 
baben  eine  Reihe  vorz'dglicher  Mittel  gegen  dasselbe.  Allen  voran  stelle  ich  den 
Schwefel,  der  fast  ein  Specificum  darstellt.  Mit  Zink  in  Form  von  Salben,  Salben- 
mullen,  Pasten  und  Leimen  ist  er  fur  die  nassende  Form  das  empfeblenswertheste, 
weil  am  rasebesten  wirkende  Mittel.  Gegen  die  schuppige  und  borkige  Form  wirkt 
der  Schwefel  aueh  gut,  noch  rascher  aber  Cbrysarobin,  Pyrogallol  und  Resorcin,  wiih- 
rend  Ichthyol  bier  dem  Schwefel  weit  nachstebt.  Sodann  baben  sich  mit  den  obigen 
reducirenden  Mitteln  in  Combination  Salicylsaure  und  Bors  iure  bewiihrt.  Dagegen 
wirken  bier  die  Hebra’scbe  Salbe  und  die  Theerpraparate  nur  uugenbgend.  Selbst 
bei  der  niissenden  Form  ist  die  Zinkschwefelsalbe  der  Bleisalbe  weit  vorzuzieben. 

Innerliche  Mittel  babe  ich  selten  notbig  gehabt.  Von  anderen  Aerzten  versebrie- 
benes  Arsenik  fand  ich  beim  seborrhoischen  Ekzem  niebt  ganz  so  prompt  wirkend  wie 
bei  Psoriasis,  obgleicb  auch  hier  eine  gute  Wirkung  uuverkennbar  ist.  Da  jedoch  die 
locale  Prophylaxis  der  Ursprungsstiitte  die  Hauptrolle  nacb  der  Heilung  der  Haut- 
krankheit  spielt,  so  bin  ich  niebt  sebr  fur  die  Arsentherapie  eingenommen,  denn  sie 
fuhrt  docb  dazu,  dass  die  Patienten  die  prophylactiscbe  Haut-  und  Haarpflege  vernach- 
lassigen,  obne  welche  auch  der  Arsenik  die  Recidive  nicht  verbindert. 

DISCUSSION. 

Dr.  Zeisler,  of  Chicago,  admired  the  striking  picture  which  Dr.  Unna  had  given 
of  a disease  so  familiar  with  us,  which  we  usually  term  seborrhoea.  He  thought  the 
occurrence  of  numerous  warts  on  the  scalp  not  very  common,  and  regarded  these  as 
due  to  hypertrophy  of  the  endothelium  of  the  sebaceous  gland. 


UBER  DIE  BEHANDLUNG  DER  SYPHILIS  MIT  INJECTIONEN 
UNLOSLICHER  QUECKSILBERSALZE. 

ON  THE  TREATMENT  OF  SYPHILIS  BY  INJECTIONS  OF  INSOLUBLE  SALTS  OF 

MERCURY. 

SUR  LE  TRAITEMENT  DE  LA  SIPHILIS  PAR  LES  INJECTIONS  DES  SELS  MERCURIALS 

INSOLUBLES. 

VON  DR.  MED.  V.  WATRASZEWSKI, 

Warschau,  Russland. 

Der  von  Prof.  Scarenzio  ausgegangene  erfolgreiche  Versuch,  statt  der  Sublimatlbsun- 
igen  fur  subcutane  Einspritzuugen  eine  Calomelemulsion  zubenutzen,  muss  entsebieden 
ds  ein  reeller  Fortschritt  in  der  hypodermatischen  Therapie  der  Syphilis  angeseben 
: werden.  Mit  einigen,  in  wbchentlichen  oder  zweiwijchentlichen  Intervallen  vollzogeuen 
Jalomelinjectionen  sind  wir  imStande,  tberapeutische  Effecte  zuerzielen,  wiedieselben 
iur  von  einer  langen  Serie  Sublimateinspritzungen  zu  Stande  gebracht  werden  kbnnen. 
Vol.  IV— 15 


226 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Die  praktische  Seite  <ler  Methode  liegt  also  auf  der  Hand.  Gestutzt  auf  die  Ergebnisae 
der  Forschuugen  in  Betreff  der  Quecksilberausscheidung  bei  den  mit  Calomelinjec- 
tionen  behandelten  Patienten,  erlangen  wir  die  Ueberzeugung,  dass  dabei  ein  gleich- 
massiger  und  langdauernder  raercurieller  Einfluss  auf  das  in  den  Geweben  und  S'aften 
eirculirende  Gift  geschaffen  wird,  was  wieder,  mit  Riicksicht  auf  die  bei  der  Syphilis- 
therapie  gewonnenen  Erfabrungen,  wir  bei  unseren  Curen  zu  bezwecken  pflegen. 

Ueber  die  giinstigen  Bebandlungserfolge  sind  wokl  alle  die  Herren  Fachcollegen 
eiuig,  die  bei  ihren  Krankeu  die  Calomelinjectionen  in  Anwendung  gebracht  baben. 
Durcb  eine  entsprecbende  Technik  und  zweckmassiges  Yerbalten  der  Patienten  ist,  wie 
wir  ans  den  spatereu  Angaben  verscbiedener  Autoren  uns  uberzeugen  kiinnen,  auch 
die  Anfangs  grosse  Zabl  consecutiver  Abscesse  bedeutend  reducirt  worden.  Trotzdem 
aber  waren  es:  der  locale,  langere  Zeit  andauernde  starke  Schmerz,  verbunden  mit  zu- 
weilen  umfangreichen  Infiltrationen  der  angestocbenen  Gegend,  sowie  die  recht  haufig 
vorkommenden  Stdrungen  des  Allgemeinbeflndens  derKranken,  Umstande,  die  sowohl 
die  Aerzte  wie  die  Patienten  uur  zu  oft  von  dem  genanuten  Bebandlungsmodus  abzu- 
scbrecken  vermochten. 

Nacbdem  nun  mit  dem  Calomel  der  erste  Scbritt  getban  ward,  lag  der  Gedanke 
nahe,  auch  andere  in  Wasser  unlosliche  Quecksilberverbindungen,  die  bis  dato  nicht 
bypodermatisch  angewandt  wurden,  einer  ahnlichen  Pr'ufung  zu  unterziehen,  um  viel- 
leicbt  in  deren  Zahl  fur  das  Calomel  ein  Substitut  zu  linden,  das  neben  einer  energischen 
specilischen  Action  keine  so  unangenehme  Nebenwirkungen  wie.jenes  besitzen  wiirde. 

Aus  erwahnten  Gr'unden  untersucbte  icb  nun  in  dieser  Richtung  folgende  Queck- 
silberverbindungen : 


Hvdrarg.  oxvdulat.  nigr 

enthaltend  96.16% 

Hydrarg.  oxvdat  rubr 

U 

92.6  % 

Hydrarg.  oxydat.  flavum 

it 

92.6  % 

Hvdrarg.  Sulfuratum 

< 1 

86.24% 

Hydr.  pracipetat.  album 

70.5% 

Hvdr.  (odat.  flavum 

a 

61.3% 

Hydr.  (odat.  rubrum 

u 

44.1% 

Hydrargyr.  tannicum  oxydulat... 

u 

50  % 

Hydrarg.  carbolic,  oxydat 

50  % 

Es  lassen  sicb  nun  die  Ergebnisse  meiner  Erfabrungen  folgendermaassen  resumiren  : 

1.  Alle  die  aufgezahlten  Praparate  kdnnen  iu  entsprecbende n Quantitaten  ohne 
Gefalu  in  Form  von  Schiittelmixturen  bypodermatisch  angewandt  werden,  gelangen  i 
auf  diese  Weise  in  den  Kreislauf  und  entfalten  im  Organismus  die  dem  Quecksilber 
eigeneu  Wirkungen. 

2.  Beim  bypodermatiscben  Gebraucbe  derselben  lasst  sicb  in  kurzer  Zeit,  spa- 
testens  nacb  48  Stunden  Quecksilber  im  Harne  nacbweisen,  und  nach  einer  Serie  von  3 
bis  6 Injectionen  kann  dasselbe  noch  lange  Zeit  nacb  der  letzeu  Einspritzung  (circa 
2 bis  4 Wochen)  in  dem  Harne  nachgewiesen  werden. 

3.  Es  werden  durcb  die  genaunten  Praparate  die  Syphilismanifestationen  erfolg- 
reich  beeinflusst,  und  daber  kdnnen  alle  dieselben  bei  der  subcutanen  Behandlung  der 
Lues  ibre  Anwendung  linden. 

4.  Bei  gleichen  hypodermatisch  benutzten  Quantitaten  der  aufgezahlten  Mittel, 
steht  im  Allgemeinen  deren  speciliscbe  Wirkung  auf  den  Organismus,  resp.  auf  die  Lues-  - 
raanifestationen  im  directen  Verh'altnisse  zu  den  in  denselben  enthalteuen  Queck- 
silber procenten.  Die  Ausnahme  biervon  bilden  die  Jodverbindungen  des  Quecksilbers,  - 
woriiber  ich  spaternocb  ein  Wort  mir  vorbebalte. 

5.  Fur  den  Grad  und  die  Intensitat  der  localen  Reaction  lassen  sich  (natUrhch 
unter  Berucksicbtigung  der  Technik,  des  Verlialtens  des  Kranken  etc.)  keine  bestimmteu 
Regeln  aufstellen.  Abgeseben  von  der  individuellen  Empfindlichkeit  der  Krankeu, 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


227 


ist  im  Allgemeinen  die  locale  Reizung  bei  den  meisten  Priiparaten  und  gleiclien  Quan- 
titaten derselben  eine  zieinlich  gleicbe  und  wiichst  dieselbe  mit  dem  Grade  der  Con- 
: centration  der  injicirten  Fllissigkeit.  Bei  manchen  Priiparaten  sehen  wir  dagegen  in 
dieser  Hiusielit  erbebliche  Unterscliiede,  die  mit  deren  chemischen  Zusammensetzung 
i (vielleicht  mit  ilirer  Bestandigkeit)  in  Yerbindung  zu  stellen  sind.  Letzteres  gilt  fur 
das  Calomel  und  das  Hydrarg.  pracipitat.  album  (amidato  bichloratum),  deren  An- 
wendung  in  der  Regel  von  einer  viel  starkeren  localen  Reaction  gefolgt  wird.  Mit  dem 
Grade  der  localen  ware  auch  die  allgemeine  Reaction  auf  den  Organismus  in  Zusam- 
menhang  zu  bringen,  d.  h.  je  starker  die  eine,  desto  mehr  ist  das  Allgemeinbefinden  des 
Kranken  beeintriichtigt  und  umgekehrt.  Doch  babe  icli  in  dieser  Hinsicht  manche 
Ausnahmen  beobachtet. 

Was  nun  die  Abscessbildung  an  den  Injectionsstellen  anbelangt,  so  baben  ent- 
i schieden  die  speciell  nach  dem  Calomel  eutstandenen  Infiltrationen  die  grosste  Tendenz, 
in  eiterige  Schmelzung  uberzugehen,  obwohl  durch  eine  entsprechende  Tecbnik,  voll- 
kommen  reine  Praparate  und  das  Verlialten  der  Patienten  die  Zahl  der  Abscesse  aufein 
Minimum  herabgesetzt  werden  kann.  Ich  miichte  fast  behaupten,  dass  von  der  ganzen 
| Reihe  der  aufgeziiklten  Praparate  diese  unerw'unschte  Complication  den  unloslicben 
i Chlorverbindungen  des  Quecksilbers  in  erster  Linie  zukommt,  da  ich  (immer  unter 
i Beriicksichtigung  der  genannten  Cautelien)  bei  den  zahlreichen  Injectionen  anderer 
Praparate  fast  nie  die  Bildung  eines  Abscesses  an  der  Einstichstelle  zu  Stande  kom- 
; men  sah.  Auch  ist  sowobl  bei  dem  Calomel  als  dem  Hydrarg.  amidato  bichloratum 
in  Betreff  der  Dauer  und  der  Entwickelung  der  localen  Reaction  (Infiltration  und 
(1  Schmerzhaftigkeit)  ein  erlieblicher  Unterschied  im  Yergleiche  mit  den  anderen  Queck- 
I silberverbindungen  zu  verzeichnen. 

W'ahrend  n'amlich  bei  Letzteren  die  localen  Reizerscheinungen  am  starksten  in  den 
1 ersten  24  bis  48  Stunden  nach  volliibter  Einspritzung  sic.h  kundgeben,  entwickeln  sich 

• dieselben  bei  dem  Calomel  und  dem  weissen  Pr'acipitate  allmalig  und  erreichen  erst 
■ gegen  den  vierten  und  fdnften  Tag  ihr  Maximum. 

Je  nach  dem  Procentsatze  an  Quecksilber  kdnnen  von  den  aufgezahlten  insolubilen 
i Mercursalzen  Quantitaten  von  0.04  bis  0.15  und  0.20  in  Form  von  Schuttelmixturen 
i ohne  jeden  Schaden  fur  den  Organismus  demselben  in  therapeutischen  Zwecken  beige- 
j bracht  werden ; und  es  stellen  sich  die  von  mir  zur  Beseitigung  der  Luesmanifestationen 

* fur  eine  Injection  benutzten  Quantitaten  der  verschiedenen  Salze  folgendermaassen  vor  : 


Quecksilberverbindung. 

Concentration 
der  Iujections- 
fliiasigkeit. 

Quantitat  des  einver- 
leibten  Salzes. 

1.  Hydr.  oxvdulatum  nigrum 

1 : 10 

0.12  grm. 

2.  Hvdrarg.  oxydat.  rubr 

1 : 10 

0.12 

3.  Hydrarg.  oxydat.  flav 

1 : 30 

0.04 

4.  Hydrarg.  Sulfurat 

1 : 10 

0.12-0.13 

5.  Hydr.  prace.  alb 

1 : 10 

0.12-0  13 

6.  Hydr.  jodat.  flav 

1 : 10 

0.12-0.13 

7.  Hydrarg.  jodat.  rubr 

1 : 7.50 

0.18 

8.  Hydrarg.  tannic.oxydul 

1 : 7.50 

0.18 

9.  Hydr.  carbol.  oxydat 

1 : 7.50 

0.18-0.19 

Da  nun  von  alien  den  aufgezahlten  Priiparaten  die  Quecksilberoxyde  den  griissten 
W Procentsatz  an  Mercur  enthalten,  so  geniigen  zur  Erzielung  einer  erwiinscliten  Wir- 
f kung  auf  den  Organismus,  resp.  auf  die  Lues,  weit  geringere  Quantitaten  derselben  als 
1 aller  anderen  Quecksilberverbindungen,  inclusive  des  Calomel,  das  84.9%  Mercur 
: enthalt,  d.  h.  weit  weniger  als  die  Oxyde.  Die  geringen  Quantitaten  des  in  die  Gewebe 


228 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


eiugeftihrten  Mittels  bilclen  nun  in  erster  Linie  den  Grund,  weshalb  die  drtlichen 
Reactionserscheinungen  bei  den  Oxyden  am  geringsten  ausfallen.  Ein  weiterer  Umstand, 
der  uns  diese  Thatsache  erkl'arlich  macht,  w'urde  in  der  Einfachheit  ihrer  cbemischen 
Zusammensetzung  und  deren  leichtem  Zersetzungsvermogen  zu  suchen  sein,  was  bei 
den  scbwer  zersetziichen  Salzen  und  speciell  bei  dem  Calomel  nicht  der  Fall  ist. 

Die  guten  Erfahrungen,  die  icb  bei  der  Behandlung  der  Syphilis  mit  Injectionen  der 
Sauerstoffverbindungen  des  Quecksilbers  und  speciell  des  gelben  Oxydes  erzielt  babe, 
und  dessen  ich  mieh  deswegen  seitdem  ausschliesslich  bediene,  wurden  bereits  im 
vergangenen  Jahre  der  Oeffentlicbkeit  Ubergeben.  Meine  weiteren  Beobachtungen,  sowie 
die  verschiedener  Fachcollegen  bestiitigen  dieselben.in  vollem  Maasse.  Vier  bis  sechs 
it  0.04-0. 06  Hydr.  oxydat.  flavi  in  wbchentlichen  Intervallen  gemachte  Einspritzun- 
gen  genfigen  in  denweitaus  meisten  Fallen  von  recenter  sowohl,  wievon  tardiver  Lues, 
zur  Erzielung  eines  erwfinschten  therapeutischen  Effectes,  ein  Erfolg,  der  mit  gleichen 
Mengen  keines  der  aufgez'ahlten,  sowohl  loslichen  als  unloslicben,  bis  jetzt  zu  hypoder- 
matischen  Injectionen  benntzten  Mitteln  hervorgebracht  werden  kann.  Bei  Benutzung 
der  anderen  Praparate  ist  entweder  eine  grossere  Anzabl  Injectionen  erforderlich,  wobei 
die  practische  Seite  der  Cur  in  den  Hintergrund  tritt,  oder  miissen  mehr  concentrirte 
Mischungen  angewandt  werden,  was  wiederum  fur  die  locale,  resp.  allgemeine  Reaction 
nicht  ohne  Belang  ist. 

Die  Ausnahme  hiervon  bildet  das  rothe  Quecksilbeijodid  (besonders  die  ersten 
Injectionen  desselben),  das  bis  0. 15-0.18  grm.  pro  Injection  ohne  auffallende  locale  noeit 
allgemeine  Reizerscheinungen  hypodermatisch  angewandt  werden  kann,  und  womit 
ich  nach  3-8  Einspritzungen,  bei  tertiaren'Luesformen  rasche  Besserung,  resp.  Heilung 
erzielt  habe.  Ungleich  schneller  wurden  aber  in  analogen  Fallen  dieselben  Resultate 
erzielt  nach  Injectionen  des  Hydrarg.  oxydat.  flavum,  unter  gleichzeitiger  Anwendung 
von  Kali  jodatum  innerlich.  Es  wfirde  sich  daher  erwiihntes  Praparat  bei  Patienten 
eignen,  die  das  Jod  innerlich  schlecht  vertragen,  ebenso  das  gelbe  Jodquecksilber,  und 
sind  nach  dessen  hypodermatischer  Application  der  locale  Schmerz,  sowie  die  Infiltration 
um  Vieles  betrachtlicher,  und  in  zwei  Fallen  habe  ich  sogar  Abscessbildung  beobachten 
kdnnen. 

Indem  ich  in  Betreff  der  Injectionstechnik  auf  meine  friiheren  diesbeziiglichen 
Publicationen  verweise,*  sei  es  mir  gestattet,  hinsichtlich  derselben  nur  auf  einige 
wichtigen  Punkte  aufmerksam  zu  rnachen,  namlich  : 

1.  Es  miissen  wiihrend  der  Injection  die  Glutealmuskeln  sich  im  Zustand  einer 
volligen  Erschlalfung  befinden. 

2.  Muss  die  Injectionsfliissigkeit  ungefahr  die  Kdrpertemperatur  besitzen,  d.  h. 
es  muss  dieselbe  dem  Kranken  warm  einverleibt  werden.  Es  geniigtdazu,  die  mit  dem  . 
Injectionsliquidum  gefdllte  Spritze  auf  einige  Secunden  fiber  die  Flamme  einer 
Weingeist-  oder  gewohnlichen  Lampe  zu  bringen. 

3.  Es  muss  nach  geschehener  Injection,  um  das  Eindringen  der  Flfissigkeit  in  den 
Stichkanal  zu  verliindern,  sofort  der  Zeigefinger  der  anderen  Hand  auf  die  Einstich- 
stelle  gebracht  und  damit  ein  Druck  in  die  Tiefe  ausgefibt  werden.  Dabei  ist  es  - 
z weckmassigjdurch  driickend-rotirende  Bewegungen  der  auf  die  Glutealgegend  aufgeleg- 
ten  ganzen  Flachhand,  womit  die  oben  gelegenen  Theile  fiber  die  tieferen  verschoben 
werden,  die  Flfissigkeit  in  den  Maschen  der  Gewebe  zur  moglichsten  Vertheiluug  zu 
bringen  suchen. 

Einen  Umstand  kann  ich  nicht  unerwahnt  lassen:  In  einigen,  obwohlrecht  seltenen 
Fallen  beobachtete  ich  nach  geschehener  Injection  von  insolubilen  Quecksilbersalzen 
Wallungen  nach  dem  Kopfe,  die  sich  durch  Hyperamie  des  Gesichtes,  Schwindel  und 
einem  Geffihl  von  Brustbeklemmung  kundgaben.  Binnen  Kurzem  und  besonders 


* Wiener  Medicinische  Wochenechri/t,  1886. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPIIY. 


229 


nach  Application  kalter  Compressen  auf  die  Stirne  schwanden  die  geschilderten 
Symptome  olme  weitere  Folgen.  Ob  nun  die  erwalmten  Erscheinungen,  die  ich  nie 
nach  den  ersten  Injectionen,  uud,  wie  gesagt,  nur  rec.lit  selten  auftreten  sah,  in  eiuer 
allgemeinen  Nervositiit  der  Patienten  ihren  Grund  hatten  oder  vielleicht  durch  directe 
Eeizung  der  unmittelbar  in  den  Kreislauf,  resp.  das  Herz  gelangten  Partikeln  des 
Medicamentes  in  Zusammenhang  zu  bringen  waren,  lasse  ich  dahingestellt.  Mit 
Riicksicht  jedocli  auf  das  Gesagte  ware  es  jedenfalls  rathsam,  bei  sanguinischen,  zu 
Kopfwallungen  geneigten,  oder  mit  Syrnptomen  von  Arteriosclerose  behafteten  Indivi- 
duen  sich  nur  ausnahmsweise  der  Injectionen  zu  bedienen. 

Zum  Schluss  will  ich  hinzufiigen,  dass  ich  bei  zwolf  Kranken  statt  der  als  Injee- 
tionsvehikel  benutzten  Gummilbsung  (im  Verhiiltnisse  von  1 : 120)  rnich  des  von 
: Frankreich  aus  empfohlenen  Vaselinum  liquidum  bediente.  Es  besitzt  jedoch  dieses 
Yebikel  keine  nenneuswerthen  Vorzuge  vor  deni  Ersteren:  obwohl  namlich  wuhrencl 
und  unmittelbar  nach  geschehener  Injection  absolut  gar  keine  Schmerzen  von  den 
Kranken  angegeben  werdeu,  pflegen  die  spiiteren  iirtlichen  Reizerscheinungen  entschie- 
den  starker  auszufallen  als  nach  der  Anwendung  des  Gummischleims,  zu  dessen 
i Gebrauche  ich  daher  bereits  zuriickgekehrt  bin. 

Indem  ich  nun  die  Resultate  meiner  Beobachtungen  in  Betreff  der  subcutanen 
Auwendung  unlbslicher  Quecksilberverbindungen  bei  der  Luestherapie  bier  vorzulegen 
mir  erlaube,  thue  ich  es  mit  der  Ueberzeugung,  dass  sobald  deren  Wirksamkeit  im 
1 Allgemeinen,  speciell  aber  einiger  derselbeu,  sowie  deren  Bequemlichkeit  in  praktischer 
Hiusiclit  eine  entsprechende  Wiirdigung  tiuden,  den  insolubilen  Mercurialsalzen  eine 
k Stelle  ersten  Ranges  bei  der  subcutanen  Syphilisbebandlung  gebuhren  d'urfte,  und  dass 

imit  Riicksicht  auf  deren  Vorzuge  vor  den  bis  clato  gebriiuchlichen,  in  Wasser  loslic-hen 
Quecksilberpraparaten,  diese  Letzteren  biunen  Kurzem  aus  der  Luestherapie  vollstandig 
verdrangt  zu  werden  verdienen. 


DISCUSSION. 

Dr.  Zeisler  emphasized  that  the  advantage  of  the  method  advocated  by  the 
reader  lays  in  the  small  number  of  injections  necessary.  He  thought  that  to  inject  a 
grain  of  sublimate  at  a dose  was  rather  dangerous,  and  said  that  in  Vienna,  where  he 
had  used  such  injections,  one  centigramme  (one-seventh  grain)  was  the  usual  dose. 

Dr.  Gottheil  said  that  we  are  favored  almost  every  few  weeks  by  our  German 
colleagues  with  some  new  method  or  new  mercurial  combination  for  the  treatment 
of  syphilis.  There  was,  however,  one  great  obstacle  in  the  way  of  our  treating  syphilis 
in  this  manner  here,  and  that  was  the  absolute  impossibility  of  getting  our  patients, 
either  in  public  or  in  private  practice,  to  submit  to  painful  procedures  such  as  these, 
when  so  very  satisfactory  results  can  be  obtained  from  oral  medication.  The  placing 
of  insoluble  mercurial  compounds  under  the  skin  does  not  seem  likely  to  become  very 
generally  adopted  in  America  for  the  treatment  of  syphilis. 

Dr.  Klotz  stated  that  he  had  some  experience  with  injections  of  insoluble  salts, 
having  made  somewhat  over  130  injections  in  eighteen  patients,  34  of  which  were 
of  calomel.  He  is  able  to  corroborate  what  Dr.  Watraszewski  had  said  about  the 
advantages  and  disadvantages  of  the  method,  the  balance  being  decidedly  in  favor 
of  the  same.  Abscesses  he  had  seen  only  three  times,  all  occurring  after  the  injec- 
tions of  calomel,  and  in  his  earlier  cases ; of  late,  he  had  seen  only  rather  painful 
infiltration  in  some  cases.  The  yellow  oxide  of  mercury  caused  much  less  pain  and 


calomel,  of  10  centigrammes,  had  given  better  results  than  twenty-five  to  thirty  iuunc- 


230 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


tions.  He  would  have  been  glad  to  hear  something  about  the  frequency  of  relapses 
after  the  injections  in  comparison  with  other  methods. 

In  contradiction  to  the  statement  made  by  Dr.  Gottheil,  that  patients  in  this 
country  would  not  submit  to  the  treatment  by  injections,  Dr.  Klotz  stated  that  his 
experience  was  almost  entirely  with  private  patients,  some  of  them  being  born  and 
brought  up  in  America.  He  found  that  the  more  intelligent  and  the  better  educated 
the  patients  were,  the  more  readily  they  would  bear  the  pain,  which,  indeed,  is  some- 
times rather  severe,  as  soon  as  they  had  understood  the  advantages  of  the  method 
and  saw  the  effects.  In  fact,  some  of  his  patients  had  voluntarily  asked  for  the 
injections  again,  in  cases  of  relapse,  in  preference  to  taking  medicines  by  the  mouth. 

Dr.  Watraszewski,  in  conclusion,  said  that  while  the  injections  were  undoubt- 
edly painful,  even  with  the  best  management,  the  patients  were  very  willing  indeed 
to  submit  to  them  when  they  saw  their  good  results.  He  had  experienced  no  trouble, 
even  in  private  practice,  in  that  way.  The  necessity  of  long  persistence  in  the  oral 
medication  was  an  argument  in  favor  of  the  new  method. 


DOUBLE  COMEDO— AN  ANATOMO-PATHOLOGICAL  STUDY. 

DOUBLE  ACNE  (COMEDO)— UNE  ETUDE  ANATOMO-PATHOLOGIQUE. 

UBER  DOPPEL-COMEDO— EINE  ANATOMISCH-PATHOLOGISCHE  STUDIE. 

BY  A.  H.  OIIMANN-DUMESNIL,  A.M.,  M.D., 

Of  St.  Louis,  Mo. 

I. 

It  is  a notorious  fact  that  statistics  in  general,  and  the  statistics  of  skin  diseases  in 
particular,  are  not  only  incomplete,  hut,  as  a general  rule,  unreliable.  In  the  case  of 
skin  diseases  it  is  well  known  that  no  adequate  estimate  can  be  formed  of  the  compar- 
ative number  of  certain  affections,  and  prominent  among  these  are  to  be  noted  the 
diseases  of  the  sebaceous  glands,  such  as  rosacea,  acne  and  comedo.  There  is  but  a very 
small  number  of  such  cases  treated  at  all,  and  of  these  only  aggravated  forms  of  the 
trouble,  as  a general  rule,  find  their  way  into  the  hands  of  specialists  ; and  it  is  only 
those  especially  interested  in  the  subject  who  keep  any  statistics  of  diseases  of  the  skin. 
On  this  account,  it  is  particularly  difficult  to  estimate  the  comparative  l’requeucy  of 
comedo,  and  still  more  so,  perhaps,  because  it  is  such  a common  affection.  It  is  now  a 
well-settled  fact  that,  like  acne,  it  is  a very  common  affection,  making  its  appearance  at 
or  about  the  time  of  puberty,  and  disappearing  spontaneously  when  adult  life  is  fully 
entered  into. 

In  regard  to  double  comedo,  all  that  can  he  said  in  regard  to  its  frequency  is  that  it 
is  of  comparatively  frequent  occurrence.  Like  comedo,  it  is  not  seen  as  often  in  females 
as  in  males,  a fact  which  would  seem  to  argue  in  favor  of  the  position  that  the  accu- 
mulation of  extraneous  matter  exercises  some  influence  in  the  plugging  up  of  the  open- 
ings of  the  sebaceous  follicles,  as  men  are  much  more  subjected  to  such  influences  than 
women.  I have  not  taken  any  particular  notice  of  the  occurrence  of  double  comedo  in 
women,  my  attention  having  been  almost  entirely  limited  to  men.  At  the  St.  Louis  City 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPII Y. 


231 


Hospital  I have  found  this  affection  present  in  about  three  and  one-half  per  cent,  of  all 
the  patients,  and  this  after  the  examination  of  several  hundreds  of  individuals  whose 
ages  ranged  from  16  to  60.  These  observations  were  made  at  various  intervals  of  time, 
sufficiently  far  apart  to  ensure  at  least  a reasonable  amount  of  time  to  allow  of  the 
rotation  of  a considerable  number  of  the  patients.  Of  course  this,  in  strict  truth,  is 
only  the  percentage  in  male  individuals  who  are  hospital  subjects,  which  is  conclusive 
evidence  of  the  fact  that,  taking  individuals  in  general — the  healthy  as  well  as  those  not 
in  health — the  percentage  of  cases  of  double  comedo  must,  without  doubt,  be  still  much 
greater.  Still,  without  actual  figures  to  rely  upon,  it  is  well-nigh  impossible  to  give 
an  accurate  estimate,  or  one  of  value.  But  even  admitting  that  the  frequency  of  occur- 
rence is  as  low  as  one  per  cent.,  there  can  be  no  doubt  of  the  relative  importance  of 
this  variety  of  comedo,  and  its  study  is  a subject  which  is  not  only  interesting  in  itself 
but  of  sufficient  importance  to  engage  the  attention  of  every  thinking  dermatologist. 
This  is  more  especially  true  as  an  investigation  into  its  pathology  and  pathogeny  is 
doubtless  destined  to  shed  some  light  upon  processes  occurring  in  other  pathological 
conditions  of  the  sebaceous  glands,  and  thus,  perhaps,  add  a little  more  to  the  meagre 
stock  of  information  which  we  possess  upon  this  subject. 

It  has  been  a matter  of  surprise  to  me  that  this  variety  of  comedo  remained  unde- 
scribed until  I published  two  preliminary  notes  on  the  subject,  in  the  Journal  of  Cuta- 
neous and  Venereal  Diseases  for  February  and  July,  1886.  After  that  a number  of  der- 
matologists observed  this  condition,  and  some  told  me  subsequently  that  they  had 
observed  it  prior  to  my  publication,  but  had  paid  no  especial  attention  to  the  fact. 
Without  even  desiring  to  impugn  the  motives  of  these  gentlemen,  I must  confess 


Fig.  1. 


that  I cannot  understand  this,  as  the  very  first  observation  made  by  me  gave  rise  to 
quite  a number  of  mental  inquiries  in  regard  to  this  variation  of  comedo,  and  excited 
such  an  interest  that  I regarded  the  fact  as  one  worthy  of  record,  and  I understand 
that  others  have  begun  to  study  the  subject,  in  order  to  elucidate  it  more  fully  and 
completely. 

It  may,  perhaps,  not  be  out  of  place  to  give  a short  description  of  this  affection, 
which,  while  it  may  not  claim  the  honor  of  being  a distinct  disease,  is,  at  least,  entitled 
to  the  position  of  a variation — and  a marked  one,  too — from  the  typical  form  of  a very 
common  affection  of  the  sebaceous  glands.  The  appearance  of  double  comedo,  in  gen- 
eral, is  that  of  comedo,  as  far  as  individual  lesions  are  concerned.  We  find,  however, 
that  there  are  two  black  points  situated  near  to  each  other,  at  a distance  of  from  one  to 
three  lines,  or  perhaps  a trifle  more.  The  two  points  form  a distinct  pair,  and,  to  the 
practiced  eye,  are  easily  recognizable  as  forming  a double  comedo.  Between  these  two 
points  the  skin  is  normal  in  appearance,  with  the  exception  of  one  thing,  viz.,  it  appears 
to  be  more  or  less  elevated,  and  to  shade  gradually  from  its  lateral  aspect  into  the 
normal  skin  (Fig.  1).  That  is,  the  appearance  presented  is  that  which  we  might  sup- 
pose would  be  produced  were  a cylinder  of  the  caliber  of  an  ordinary  pin  or  a little 
larger,  and  of  a length  equal  to  that  between  the  points,  introduced  beneath  the  skin. 
Upon  passing  the  hand  over  this  portion  of  skin,  this  slight  elevation  can  be  distinctly 
perceived.  Both  points  are  markedly  blackened,  and  may  be  situated  on  a level  with 
the  surrounding  skin,  or  they  may  be  slightly  raised  with  it  and  produce  a small  papular 
elevation,  or  be  very  slightly  elevated  above  the  general  plane  of  the  cutaneous  surface, 


232 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


giving  the  nutmeg-grater  sensation  which  is  sometimes  observed  in  comedo.  If  lateral 
pressure  he  exercised  over  one  of  the  black  points  by  means  of  a spatula  or  similar 
instrument,  a plug  will  be  forced  out,  whose  shape  is  cylindrical  and  which  has  a black- 
ened end  at  each  extremity  (Fig.  2).  The  length  of  this  plug  corresponds  to  the  dis- 
tance between  the  two  black  points  observed  before  it,s  expulsion.  If  we  now  take  a 
pin  or  piece  of  wire  it  can  be  easily  introduced  at  one  orifice  and  be  caused  to  protrude 
at  the  other,  thus  demonstrating  that  there  exists  a horizontal  canal  (Fig.  3).  This 
canal  is  one  whose  shape  is  slightly  curved,  but  not  sufficiently  so  to  prevent  the  easy 
introduction  of  a probe,  such  as  mentioned  above,  even  if  the  instrument  be  straight, 
although  greater  ease  of  introduction  is  obtained  by  giving  the  instrument  a slight 
curve  corresponding  to  that  of  the  canal. 

In  this  connection  I wish  to  mention  here  that  I have  met  further  modifications  of 
this  condition.  There  are  cases  in  which  are  found  not  only  two,  but  three  and  even 
four  comedones,  communicating  with  each  other  in  the  same  manner,  and  a probe  can 
be  passed  through  auy  two  without  any  difficulty,  thus  showing  the  connection  existing 
between  the  various  openings  (Fig.  4).  These  forms  might  properly  be  denominated 
multiple  comedo.  Any  attempt  made  to  express  the  contents  of  any  one  of  these  varie- 
ties results  either  in  the  form  of  a portion  of  a plug,  pigmented  at  one  extremity,  or 
of  one  colored  at  both  ends.  This,  of  course,  would  be  naturally  expected  when  we 
consider  the  conditions  which  are  present.  Owing  to  certain  unavoidable  circum- 
stances, I have  not  been  enabled  to  remove  the  portion  of  skin  included  by  the  black- 


Fig.  2.  Fig.  4.  Fig.  5. 


ened  points,  or  I might  have  had  the  opportunity  of  removing  the  underlying  sebaceous 
mass  entire.  There  is  no  doubt  in  my  mind,  however,  that  the  condition  present  is  one 
in  which  there  are  three  or  more  plugs,  having  a common  centre  and  blackened,  each 
one  at.  its  extremity  (Fig.  5),  and,  consequently,  of  a more  or  less  stellate  form.  The 
reason  for  this  conclusion  will  be  developed  later  on. 

This  form  occurs  wherever  we  find  comedo,  and  this  is,  in  general  terms,  limited  to 
the  face,  neck  and  shoulders,  the  back  being  also  tbe  seat  of  the  disease.  The  principal 
locality  affected  by  double  comedo,  in  my  experience,  is  that  portion  of  the  integu- 
ment of  the  face  which  is  located  over  the  malar  eminences,  or  directly  underneath  them. 
I have  never  observed  any  upon  the  forehead  or  chin.  The  posterior  and  lateral  aspects  of 
the  neck  are  frequently  affected ; more  so,  in  fact,  than  other  portions  of  the  cervical  area. 
The  upper  portions  of  the  shoulders  and  the  skin  over  the  scapula;  are  the  parts  of  the  back 
most  frequently  the  seat  of  double  comedo,  although  I have  seen  cases  where  the  trouble 
was  irregularly  distributed  over  the  entire  dorsal  aspect  of  the  trunk.  A careful  examina- 
tion has  revealed  the  presence  of  this  affection  upon  the  chest,  in  but  a very  few  cases. 
The  number  is  so  small  that  its  location  here  maybe  considered  as  being  rather  unusual. 
I have  also  observed  it  in  the  ears,  but  its  location  at  this  site  is  rather  exceptional,  as 
also  upon  the  nose.  I may  state,  parenthetically,  here,  that  the  number  of  double 
comedones  in  comparison  with  that  of  single  ones,  in  any  individual,  is  excessively 
small.  Yet  I have  seen  a case  in  which  there  seemed  to  be  no  other  form  than  the 
double,  and  these  were  present  in  large  numbers. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


233 


The  size  of  the  openings  of  the  glands,  in  double  comedo,  varies  to  some  extent. 
The  holes  are  often  larger  than  an  ordinary  sized  pin ; while,  at  times,  they  are  exceed- 
ingly small,  so  small,  in  fact,  that  it  is  with  difficulty  that  the  wires  employed  lor 
keeping  fine  hypodermic-syringe  needles  clean,  can  be  introduced.  In  this  fine  form, 
the  bridge  of  intervening  skin  is  of  a marked  degree  of  thinness  and  the  dark  points, 
showing  the  openings  of  the  ducts,  are  quite  closely  approximated,  the  distauce  being 
a line  or  even  less. 


II. 

Before  considering  the  pathology  of  double  comedo,  it  may  not  be  out  of  place  to 
give  a hasty  review  of  the  development  and  anatomy  of  the  sebaceous  glands,  together 
with  a short  notice  of  the  pathology  of  comedo.  The  subject  of  development  is  one 
which  is  always  of  the  highest  interest,  and  there  has  been  but  comparatively  little  work 
done,  so  far,  in  this  brauch,  on  account  of  the  vast  territory  which  must  of  necessity  be 
covered.  Although  the  modern  division  of  medicine  into  a number  of  special  depart- 
ments has  given  an  impetus  to  special  research,  the  time  has  been  too  short  to  permit 
any  one  to  say  that  he  has  completely  exhausted  any  one  subject.  It  is  for  these  reasons 
that  I do  not  hesitate  to  say  a few  words  concerning  the  development  of  the  sebaceous 
glands,  upon  which  there  seems  to  have  been  but  little  written,  up  to  the  present  time. 
In  all  the  literature  to  which  I have  had  access,  the  only  author  who  makes  any 
extended  mention  in  regard  to  this  subject  is  Kolliker  in  his  “ Entwickelungs- 
geschichte, ” and  his  work  on  this  subject  is  by  no  means  as  complete  as  it  might  be. 

The  sebaceous  glands  begin  to  make  their  appearance  at  about  the  fourth  month  of 
development,  in  the  human  embryo.  This  is  the  earliest  indication,  and  we  find  it  on 
the  sides  of  the  forehead.  About  the  fifth  month  these  glands  are  developing  in  nearly 
every  portion  of  the  body  and,  at  this  period,  can  be  found  in  almost  every  stage  of 
development.  The  drawings  which  are  appended  are  from  preparations  obtained  from 
the  scalp  of  an  embryo  between  the  fifth  and  sixth  months,  and  three  stages  in  the 
development  of  the  sebaceous  gland  are  represented.  Even  in  a very  small  space  we 
are  enabled  to  find  such  examples.  What  the  reason  of  this  is  has  not  been  satisfac- 
torily explained.  As  Eschricht  observed  long  since,  this  development  is  pari  passu  with 
the  development  of  the  hair  and  its  follicle,  a circumstance  which  would  seem  to  indi- 
cate that  the  gland  is  a mere  outshoot  of  the  other,  confirmatory  proof  of  which  is 
furnished  by  the  various  stages  of  development. 

The  first  indication  of  a sebaceous  gland  consists  in  a thickening  of  the  wall  of  the 
hair  follicle  (Fig.  6).  This  consists,  apparently,  of  a proliferation  of  cells  which  has 
taken  place  between  the  internal  and  external  layers,  and  has  thus  formed  this  boss  or 
bulging  portion . At  first  scarcely  perceptible,  it  becomes  more  and  more  prominent, 
and  pretty  soon  it  stands  out  in  a well-defined  manner.  In  another  and  more  advanced 
stage  we  find  that  some  differentiation  of  form  begins.  A greater  or  less  constriction 
takes  place  at  a point  of  the  projection  which  corresponds  approximately  to  the  niveau 
of  the  outer  part  of  the  external  layer  of  the  root  sheath  of  the  hair  (Fig.  7).  This 
constriction  then  increases  on  the  lower  side,  and  the  entire  mass  apparently  tails  and 
assumes  somewhat  of  a pyriform  or  flask  shape,  or  looks  like  a bud  growing  downward 
(Fig.  7).  In  time,  this  form  becomes  more  or  less  marked,  until  it  may  extend  even 
lower  down  than  the  level  of  the  hair  follicle,  or  it  may  never  extend  beyond  a very 
slight  distance  from  the  point  where  the  original  bulging  took  place. 

We  see  all  of  these  stages  well  defined,  and  there  is  no  difficulty  whatever  in  tracing 
the  relations  between  them.  They  are  plainly  derivatives  one  of  the  other.  The  scalp 
of  a five  and  one-half  months’  feetus  will  show  these  very  well,  especially  if  that  por- 
tion be  taken  which  lies  directly  in  front  of  and  above  the  ear. 

As  will  be  shown  later  on,  the  sebaceous  gland  is  surrounded  by  a very  thin  and 


234 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


apparently  structureless  membrane  which  holds  a layer  of  cells  in  position.  We  find 
that,  in  the  development  of  the  hair,  a membrane  forms  around  the  external  layer  of 
the  root  sheath,  and  when  the  bulging  takes  place,  to  form  the  future  sebaceous  gland, 
this  membrane  is  pushed  out,  and  ultimately  becomes  the  support  of  the  walls  of  the 
gland. 

The  structure  of  the  mass  which  is  to  become  the  sebaceous  gland  is  the  same,  in 
general,  as  that  of  the  root  sheath  at  the  point  where  the  bulging  takes  place.  We 
have  this  boss,  composed  chiefly  of  polygonal  or  round  cells,  distinctly  nucleated  (the 
nuclei  being  large)  and  somewhat  closely  packed  together.  These  cells  are,  at  first, 
continuous  with  those  of  the  root  sheath  (Fig.  7),  but  changes  take  place  later  on. 

We  know  that  the  hair  is  an  epidermal  structure,  and  that  it  is  formed  by  a dipping 
in  of  the  epidermis  into  the  skin.  The  layers  of  the  root  sheath  correspond  to  those  of 
the  epidermis.  After  the  primitive  hair  cone  has  become  differentiated,  the  develop- 
ment of  the  sebaceous  gland  begins.  By  this  time  we  are  enabled  to  see  that  the  inner- 


Fig.  6. 


most  layer  of  the  root  sheath  corresponds  to  and  is  continuous  with  the  horny  layer  of 
the  epidermis  ; in  like  manner,  the  external  layer  of  the  root  sheath  corresponds  to  the 
lowest  layer  of  cells  of  the  mucous  layer  of  the  epidermis,  or  what  becomes,  later  on, 
the  pigment  cells  of  the  rete  mucosum. 

Now,  it  is  well  known  that  this  layer  differs  from  the  other  portions  of  the  rete  • 
Malpighii,  in  the  fact  that,  while  those  portions  are  composed  of  polygonal  cells  of  a 
particular  character— the  prickle  cells — those  forming  the  lowest  layer,  and  situated 
immediately  over  the  papilke,  are  columnar  and  arranged  side  by  side  in  a very  regular 
manner;  besides  which,  they  generally  contain  pigment.  These  very  characteristics, 
of  being  columnar  cells  and  arranged  in  a regular  manner,  are  observed  in  the  lining 
cells  of  the  sebaceous  gland  in  a very  early  stage  of  its  development  (Fig.  7),  and  by 
exercising  a little  care  in  the  examination,  this  layer  of  cells  will  be  found  to  be  con- 
tinuous with  a similar  one  in  the  root  sheath,  and  this  latter,  in  turn,  with  that  of  the 
rete  Malpighii. 

To  return  to  the  development  proper  of  the  gland:  When  its  growth  has  arrived  at 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


235 


that  stage  when  it  is  pyriform,  a change  begins  to  take  place  in  the  central  portion. 
Some  of  the  cells  begin  to  change  in  appearance,  and  it  is  noticed  that  fatty  degenera- 
tion is  beginning  to  take  place.  This  goes  on  in  all  directions  and  in  a comparatively 
rapid  manner.  After  a certain  time,  this  fatty  metamorphosis  extends  into  the  con- 
stricted portion  of  the  mass  (Fig.  8)  and  works  its  way  gradually  toward  the  internal 
surface  of  the  root  sheath.  When  this  locality  is  finally  reached,  the  cells,  filled  with 
oil  globules,  find  their  way  between  the  hair  shaft  (which  is  now  formed)  and  the  root 
sheath,  and  we  have  the  first  indication  of  sebum.  In  this  process  the  innermost 
layer  of  the  root  sheath  is  destroyed  at  the  point  where  these  cells  force  their  way,  and 
we  have  the  duct  from  the  sebaceous  gland  to  the  hair  sac  fully  established. 

This,  of  course,  is  merely  an  outline  sketch  of  the  development  of  one  acinus.  The 
others  are  formed  in  a similar  manner  by,  so-to-speak,  secondary  bulgings,  and  these  in 
turn  become  pedunculated  and  form  their  canals.  The  limitation  of  the  number  of 
lobules  is  probably  due  to  the  relative  density  of  the  surrounding  tissues,  as  the  more 


Fig.  8. 


dense  they  are  the  greater  will  be  the  resistance  to  be  overcome,  and  consequently,  the 
smaller  the  number  of  acini.  Should  there  be  but  little  or  no  appreciable  resistance  in 
any  particular  direction,  it  may  happen  that  lobules  forming  there  will  become  much 
larger  than  the  parent  and  usurp,  to  a considerable  degree,  its  functions. 

The  sebaceous  gland,  in  general,  is  merely  a secondary  growth.  It  is  developed  from 
the  root-sheath  of  the  hair  and  only  after  the  hair  itself  has  developed  to  a certain 
degree.  The  gland  depends  for  its  existence  upon  the  hair-sheath,  and  although  it  may 
grow  to  such  dimensions  as  to  make  the  hair  really  secondary  to  it  in  importance,  it 
still  remains  the  offspring  of  the  latter.  This  would  seem  to  confirm  the  opinion  long 
held  by  many  dermatologists,  that  the  glands  have  for  their  function  the  lubrication  of 
the  hair.  It  is  only  natural  that,  where  hair  has  apparently  disappeared,  as  a result  of 
evolution  ; or  rather,  that  in  those  localities  where  hair  is  very  rudimentary,  the  more 
vital,  the  better  nourished  and  more  important  layers  of  cells  should  thrive  more,  and 
this  may,  in  part  at  least,  account  for  the  presence  of  largo  sebaceous  glands  in  con- 
junction with  the  fine  lanugo  hairs. 


23G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  considering  tlie  development  of  the  sebaceous  gland,  it  was  stated  that  the  central 
cells  undergo  fatty  degeneration,  this  being  probably  due  to  pressure  and  lack  of  pabu- 
lum combined.  Now,  why  do  not  the  other  cells  also  suffer  this  change  ? This  is  a 
difficult  question  to  answer  with  any  degree  of  accuracy  or  of  satisfaction  ; yet,  it  seems 
not  unreasonable  to  suppose  that  the  columnar  cells  retain  a good  many  of  the  charac- 
teristics which  were  inherent  in  them  when  they  formed  a part  of  the  developing  skin. 
In  the  mucous  layer,  they  possess  a great  deal  of  resisting  power  and  carefully  guard 
the  corium  against  any  encroachments  from  without.  They  seem  well  adapted  to  resist 
pressure,  and  this  is  probably  the  reason  they  escape  fatty  metamorphosis  in  the  seba- 
ceous glands.  Besides  this,  they  constitute  a wall,  and  give  form  and  solidity  to  this 
wall.  They  are  rather  cuneiform  at  first,  and  are  arranged  so  as  to  form  arches  as  per- 
fect in  construction  as  could  be  possibly  desired.  This  construction,  of  course,  greatly 
increases  the  power  of  resisting  external  pressure  during  the  process  of  development  of 
the  gland.  Later  on,  when  some  pressure  is  not  only  necessary  but  desirable,  we  find 
that  the  form  and  the  distribution  of  these  cells  have  changed,  and  this  will  be  men- 
tioned in  the  consideration  of  the  anatomy  of  the  sebaceous  glands. 

There  is  a somewhat  different  development  which  takes  place  in  the  case  of  glands 
which  open  directly  upon  the  surface  of  the  skin.  Here,  instead  of  a bulging  of  the  hair 
sheath,  we  have,  so  to  speak,  an  absence  of  hair  development ; and,  what  might  other- 


wise have  become  a hair  becomes  a sebaceous  gland,  in  a manner  similar  to  that  already 
described.  A dipping-in  of  the  epidermis  takes  place  (Fig.  9)  and  the  lower  extremity 
becomes  larger,  the  entire  prolongation  consisting  at  first  of  a mass  of  cells,  as  in  the 
primitive  hair.  The  process  already  described  takes  place,  and  by  the  further  enlarge- 
ment of  the  lower  portion  we  have  a sebaceous  gland  formed  whose  different  acini  are 
secondarily  formed  by  a species  of  budding.  The  fact  that  the  mode  of  development  is 
primarily  the  same  as  that  of  a hair,  and  that  the  differentiation  takes  place  as  it  does, 
would  seem  to  argue  that  the  arrest  of  hair  development  which  takes  place  is  merely 
in  accord  with  the  general  process  of  evolution  which  is  going  on  gradually  in  man. 
Even  in  some  of  these  glands  it  is  not  so  clear  that  a primitive  attempt  at  a hair  does 
not  take  place  only  to  be  cast  off  without  the  formation  of  a papilla. 

As  is  well  known,  sebaceous  glands  are  of  three  varieties,  viz.  : — 

1.  Those  which  open  directly  into  a hair  follicle. 

2.  Those  opening  upon  the  skin  and  associated  with  rudimentary  hairs. 

3.  Those  opening  directly  on  the  surface  but  not  associated  with  hair. 

The  minute  anatomy  of  all  of  these  is  about  the  same.  There  is  an  outer  envelope 
of  a more  or  less  structureless  membrane  which  is  supported  by  connective  tissue.  This 
membrane  is  the  basement  membrane  of  the  gland  and  serves  as  a framework  upon 
which  the  lining  cells  find  support.  These  cells  still  continue  to  retain  their  charac- 


Fig.  9. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


237 


teristics,  being  in  general  columnar,  with  large  and  distinct  nuclei,  and  capable  of 
resisting  quite  an  amount  of  pressure,  as  will  be  shown  later  on.  Although  these  cells 
are  said  to  be  arranged  with  great  regularity,  we  occasionally  find  specimens  in  which 
they  appear  rather  irregularly  placed  (Fig.  10).  Within  these  cells  are  found  numerous 
polygonal  or  roundish  cells  containing  nuclei  which  are  large.  These  cells,  as  the  centre 
of  the  gland  is  approached,  are  seen  in  various  stages  of  fatty  degeneration,  and  some- 
times there  seems  to  be  an  abrupt  change  from  the  cells  to  the  swelled-up,  bladder-like 
A’esicles  containing  almost  nothing  but  fat  and  very  indistinctly-marked  nuclei  (Fig.  10. ) 
The  origin  of  the  cells,  which  are  constantly  appearing  to  undergo  fatty  degeneration, 
is  a question  Avhich  has  for  a long  time  occupied  the  attention  of  microscopists  and  it 
seems  destined  to  be  solved  ere  long.  The  whole  question  rests  upon  the  solution  of 
the  problem  as  to  whether  the  basement  layer  of  columnar  cells  is  concerned  in  this 
reproduction,  or  whether  the  polyhedral  cells  nearest  this  basement  layer  are  produc- 
tive of  the  proliferation.  A study  of  the  karyokinesis  of  these  elements  will  probably 
give  the  requisite  solution.  Be  this  as  it  may,  the  greater  portion  of  the  interior  of  the 
gland  is  filled  with  fatty  matter  and  epithelial  debris  which  is  continually  finding  its 
way  to  the  outer  world  and  being  produced. 

The  somewhat  irregular  distribution  and  slight  variations  in  the  forms  of  the  col- 
umnar cells  lining  the  sebaceous  gland  are  most  probably  due  to  the  varying  amount  of 
pressure  brought  to  bear  upon  them  by  the  skin  under  varying  conditions.  This  also 


Fig.  10. 


tends  to  produce  a greater  or  less  adaptability  of  the  gland  walls  to  pressure  without 
seriously  interfering  with  the  texture  of  the  gland,  and  thus  afford  them  some  aid  iu 
the  expulsion  of  their  contents.  To  say,  however,  that  this  expulsion  is  due  to  the 
action  of  the  arrectores  pilorum,  or  that  the  movements  of  the  skin  play  any  consider- 
able part  in  this,  seems  to  me  to  be  incorrect.  A much  simpler  explanation  is  that  the 
cells  nearest  the  duct,  being  the  oldest,  have  undergone  fatty  degeneration  much  more 
thoroughly  than  those  immediately  behind  them,  and  so  on.  As  new  cells  proliferate 
near  the  periphery,  they  exercise  pressure  on  those  immediately  in  front  of  them,  and 
this  pressure  is  transmitted  in  the  line  of  least  resistance,  and  we  have,  in  consequence, 
an  escape  of  sebum  into  the  hair  follicle  or  upon  the  skin,  as  the  case  may  be.  In  the 
second  and  third  varieties  of  sebaceous  glands  mentioned  above,  there  are  no  hair 
muscles  and  yet  the  sebum  finds  its  way  to  the  surface,  thus  demonstrating  that  the 
muscles  play  no  essential  part  in  this. 


III. 

In  regard  to  the  production  of  comedo,  there  seems  to  be  some  difference  of  opinion 
in  respect  to  details.  A careful  consideration  will  show,  however,  that  one  of  two 
causes  is  generally  at  work.  One  is  external  and  purely  mechanical;  the  other  internal 
and,  to  some  degree,  organic.  In  the  first,  the  mechanism  consists  simply  iu  a plug- 


238 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ging  up  of  the  mouth  of  the  duct,  foreign  matter  becoming  wedged  in,  so  to  speak. 
The  sebaceous  material  behind  this  is  unable  to  overcome  the  resistance,  and,  as  a 
natural  result,  accumulates.  More  or  less  inspissation  takes  place,  especially  of  that 
portion  in  the  duct;  and  the  material,  continuing  to  increase  in  quantity,  exercises  a 
slow  and  constant  pressure.  If  this  continues  long  enough,  the  gland  dilates  and  its 
acini,  also,  until  we  have  the  organ  simply  transformed  into  a sac,  the  duct  disappear- 
ing more  or  less  completely  (Fig.  11).  When  the  cause  is  internal,  the  cells  do  not 
undergo  complete  fatty  metamorphosis,  and  the  resulting  mass  is  somewhat  hard,  the 

Fig.  11. 


envelope  tough,  and  a combination  of  several  produce  a plugging-up  of  the  outlet  of  the 
gland.  The  process  is  the  same  as  in  the  first  instance,  with  the  exception  of  being, 
perhaps,  a little  more  irritating.  Extraneous  matter  falls  in  the  opening  of  the  follicle, 
and  a comedo,  which  is  extremely  dry  and  difficult  to  force  out,  is  the  result.  It  seems 
that,  after  a certain  length  of  time,  there  is  an  apparent  cessation  of  cell  formation  and 
dessication  goes  on,  the  plug  separating  from  the  walls  of  the  sac-like  gland,  as  shown 
in  Figs.  11  and  12,  but  seemingly  attached  to  the  opening  of  the  duct. 

In  all  the  specimens  which  I have  examined,  I have  found  that  the  cavity  was  lined 


Fig.  12. 


by  a membrane,  seemingly  structureless,  and  upon  which  no  cells  could  be  found. 
They  may  have  fallen  out,  but  it  is  more  probable,  as  B'arensprung  suggested  long  ago, 
that  after  the  accumulation  of  sebum  has  remained  a long  time  the  secreting  structure 
becomes  lost  to  a certain  extent,  the  continued  pressure  producing  more  or  less  absorp- 
tion. That  a comedo  may  be  old  and  still  contain  secretory  cells,  has  been  demon- 
strated by  Bulkley,  but  that  these  cells  may  entirely  disappear  has  also  been  well 
established. 


SECTION  XIV DERMATOLOGY  AND  SYPHILOGRAPHY 


239 


In  double  comedo  we  have  a condition  that  is  the  exact  analogue  of  that  found  in 
the  single  variety.  A large  roundish  cavity  is  found,  lined  throughout,  as  in  comedo, 
and  tilled  with  a plug  of  sebaceous  matter  having  two  extremities,  each  one  of  which 
shows  its  darkened  end  at  an  opening  (Fig  12).  The  plug  has  the  same  general  char- 
acteristics as  in  the  other  form,  and  differs  from  it  only  in  the  fact  that  it  has  two  ex- 
tremities. The  manner  of  formation  is  the  same  as  in  the  other,  after  the  cavity  has 
been  formed. 

In  regard  to  the  formation  of  this  cavity,  there  can  be  but  one  of  two  solutions.  In 
the  first  place  we  must  suppose  a condition  which  I consider  entirely  untenable,  viz. : 
that  there  is  a congenital  deviation  in  the  form  of  the  sebaceous  gland— in  other  words, 
that  one  gland  has  two  ducts.  The  careful  examination  of  many  infants  and  children 
has  failed  to  show  this  condition.  In  adults,  it  has  not  been  found  in  those  cases  where 
no  comedo  existed.  Yet  the  comparative  frequency  of  double  comedo  is  such  that  we 
might  reasonably  expect  to  find  such  a condition  where  the  disease  depended  upon  a 
congenital  condition  of  this  kind.  The  only  reasonable  solution  which  I can  offer  is 
this,  that  two  sebaceous  glands,  in  close  proximity  to  each  other,  are  each  one  the  sub- 
ject of  comedo.  In  each  one  the  inspissation  is  marked  and  accumulation  of  the  con- 


Fig.  13. 


tents  becomes  such  that  the  small  amount  of  tissues  existing  between  the  two  is  sub- 
jected to  a pressure  such  that  it  simply  produces  absorption  of  that  septum  and  fuses 
the  two  cavities  into  one.  That  there  is  a tendency  for  such  pressure  to  exist  and  be 
produced  is  probable  from  the  fact  that,  in  “ single  ” comedo  from  the  same  individual 
and  in  the  neighborhood  of  the  double  one  observed,  there  remains  nothing  of  the  inter- 
nal or  lining  structure  but  the  membrane  already  alluded  to.  The  objections  to  this 
are  the  following:  1st.  If  this  lining  membrane  is  absorbed  in  both  glands,  where  they 
touch,  why  is  it  that  it  is  not  absorbed  in  other  portions?  This  is  answered  by  the 
fact,  that,  where  absorbed  these  membranes  cannot  push  other  tissues  before  them,  being 
opposed  one  to  the  other  ; whereas,  in  other  portions,  the  connective  tissue  surround- 
ing them  gives  way.  2d.  Why  are  not  remains  of  this  septum  to  be  seen  ? This,  of 
course,  is  not  easy  to  answer.  As  a matter  of  fact,  I have  not  been  able  to  discover 
any  remains,  the  minute  structure  of  the  wall  of  the  gland  being  throughout  as  repre- 
sented in  Fig.  13.  We  have  here  a structureless  membrane  outside  of  which  there 
exists  a cellular  layer,  containing  fibres;  and,  external  to  this,  connective  tissue.  There 
is  no  break  in  the  membrane,  at  any  point,  nor  is  there  any  projecting  tissue  or  por- 
tion of  it.  It  appears  all  around  as  a homogeneous,  structureless  mass,  of  equal  thick- 


240 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ness  throughout  .and  staining  a lighter  color  than  the  rest.  It  seems  to  participate  in 
the  nature  of  epidermal  tissue  in  composition. 

The  probability  of  double  comedo  being  formed  by  the  fusion  of  two  single  lesions 
is  rendered  still  greater  by  the  fact  that  lesions  are  found  in  which  three  or  four  open- 
ings communicate  with  one  sebaceous  cavity.  It  is  more  reasonable  to  ascribe  these 
“ multiple  ” comedones  to  the  action  of  several  single  ones,  by  pressure  absorption  than 
to  suppose  the  existence  of  a number  of  anomalies,  with  the  necessity  of  having  a new 
one  to  fit  each  new  case,  whereas,  in  the  other  instance,  one  general  and  simple  law 
suffices  to  explain  every  example. 

DISCUSSION. 

% 

Dr.  Unna  believed  double  comedo  never  developed  in  a normal  skin  ; that  at  some 
time  there  had  been  an  inflammatory  process  in  that  part,  followed  by  cicatrization. 

Dr.  Ohmann-Dumesnil,  in  closing,  said  he  did  not  believe  in  the  necessity  of  a 
preexisting  inflammatory  process,  and  had  failed  to  find  scars  in  many  cases. 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGRAPHY. 


241 


FIFTH  DAY. 


Dr.  Thin,  London,  presiding. 

THE  PATHOLOGY  AND  TREATMENT  OF  ALOPECIA  AREATA. 

LA  PATHOLOGIE  ET  LE  TRAITEMENT  DE  L’ALOPECIE  PAR  PLAQUES. 

UBER  DIE  PATHOLOGIE  UND  BEHANDLUNG  DER  ALOPECIA  AREATA. 

BY  A.  R.  ROBINSON,  M.B.,  L.R.C.P.  & S. , EDIN. 

Of  New  York. 

In  attempting  to  open  a general  discussion  on  alopecia  areata  I am  not  unaware  of 
the  difficulty  of  the  task;  for  perhaps  no  subject  in  dermatology  has  given  rise  to  more 
scientific  discussion,  or  upon  which  such  opposite  views  exist,  than  that  of  the  aetiology 
of  this  disease.  The  believers  in  the  parasitic  origin  have  advanced  many  arguments 
founded  upon  microscopical  study  of  the  hairs  and  epidermis  of  the  affected  parts,  as 
well  as  deductions  and  analogies  from  the  clinical  symptoms  and  result  of  methods  of 
treatment,  to  prove  either  the  positive  presence  of  organisms  or  the  almost  certainty  of 
their  existence  as  the  aetiological  factor  of  the  disease;  at  the  same  time  they  have 
endeavored  to  show  that  there  is  no  real  basis,  either  in  the  clinical  symptoms  or  other- 
wise, for  the  trophoneurotic  theory.  And,  on  the  other  hand,  those  who  regard  the 
disease  as  a neurosis — and  they  are  at  present  greatly  in  the  majority — maintain,  with 
equal  positiveness,  that  the  clinical  symptoms  are  not  those  of  a parasitic  disease,  and 
that  microscopical  examination  has  failed  to  show  any  organism  having  a proven  aetio- 
logical relationship  to  the  affection  ; but  that  all  of  the  symptoms  of  the  disease,  even 
the  peculiar  manner  of  extension  of  the  patches  at  the  periphery,  are  not  only  not 
opposed,  but  are  in  favor  of  its  having  a neurotic  origin.  As  an  impartial,  even  if  a 
somewhat  incompetent,  j udge  of  the  value  of  the  statements  and  views  of  the  advocates 
of  the  two  theories,  I will  now  endeavor  to  briefly  review  and  criticise  the  arguments 
of  both  sides  as  given  us  by  their  advocates  up  to  the  present  time,  and  thus  attempt 
to  find  out  whether  we  are  justified  from  the  facts  obtained  concerning  its  aetiology — the 
result  of  a study  of  the  symptoms,  natural  history,  results  of  treatment,  and  micro- 
scopical examinations,  in  forming  definite  conclusions  as  to  the  cause  of  the  disease. 

Before  accepting  the  parasitic  theory  it  must  be  shown  that  a definite  organism  is 
always  present  at  the  commencement  of  the  disease — an  organism  not  found  under 
normal  states  or  concerned  with  other  pathological  conditions;  that  the  pathologico- 
anatomical  changes  in  the  affected  part  are  the  result,  directly  or  indirectly,  of  their 
presence,  or,  finally,  that  the  disease  is  contagious.  Cultures  with  inoculations  would, 
if  successful,  naturally  confirm  the  view  of  their  positive  ajtiological  significance,  but 
this  is  not  absolutely  necessary.  I say  an  organism  must  always  be  present  at  the 
commencement  of  the  disease,  but  if  the  eruption  is  not  spreading  their  absence  in  that 
case  would  not  be  proof  against  their  existence  in  an  earlier  stage,  as  the  continued 
existence  of  an  area  of  the  skin  devoid  of  normal  hair  could  be  the  result  of  anatomical 
conditions  of  the  part  arising  from  their  previous  presence,  just  as  we  may  have  a per- 
Vol.  IV— 10 


242 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


manent  alopecia  produced  by  the  favus  fungus  and  continuing  long  after  the  organisms 
have  ceased  being  present. 

So,  also,  if  we  find  organisms  which  are  not  met  with  on  or  within  the  skin  in  any 
other  condition,  and  their  situation,  number,  etc.,  would  clearly  explain  any  patho- 
logico-auatomical  changes  of  the  part  in  which  they  are  situated,  and  no  other  explana- 
tion of  these  changes  would  be  at  all  probable,  then  I think  we  would  be  justified  in 
accepting  them  as  the  cause  until  the  opposite  was  proven,  as  is  the  case,  for  instance, 
in  tinea  versicolor.  If  the  disease  is  contagious — and  I mean  by  that  positive,  indis- 
putable proof  of  its  occurrence,  and  not  a possible  coincidence  of  the  same  disease 
occurring  in  persons  who  associate  together — a contagious  power — such,  for  instance,  as 
we  have  in  measles— then*  with  our  present  knowledge  of  bacteria,  it  would  not  be 
necessary  to  demonstrate  the  organism  to  prove  the  origin  of  the  disease. 

Before  accepting  the  neurotic  theory,  the  clinical  history  should  point  very  strongly 
in  that  direction,  or  the  microscopical  examination  should  show  changes  in  the  nerve 
.tissue  or  in  the  skin  somewhat  similar  to  those  occurring  in  well-known  neuroses,  or, 
finally,  one  should  be  able  to  produce  the  disease  at  will  by  producing  certain  injuries 
to  certain  portions  of  the  nervous  system.  The  upholders  of  this  theory  must  show 
that  the  almost  invariably  circular  shape  of  the  patches,  their  manner  of  spreading  at 
the  periphery,  as  well  as  many  other  characters,  are  consistent  with  their  view;  that 
anatomical  changes,  if  any,  are  such  as  are  known  to  result  from  trophic  disturbances 
of  nutrition;  and,  finally,  that  if  an  alopecia,  the  result  of  certain  experiments,  be 
produced,  all  the  spots  must  have  the  characters,  in  every  respect,  of  ordinary  alopecia 
areata. 

Any  criticism  I shall  attempt  upon  the  views  of  gentlemen  who  have  written  upon 
the  subject  will  be  based  upon  the  foregoing  conditions  for  proof  of  causation,  using  the 
clinical  symptoms  of  the  disease,  the  anatomical  changes  of  the  part,  as  they  have 
hitherto  been  described,  and  the  results  of  modes  of  treatment,  as  evidence  for  or 
against  the  two  theories,  as  the  case  may  be. 

Let  us  first  consider  the  value  of  the  arguments  advanced  by  those  who  believe  in 
the  parasitic  origin.  And  here  I wish  to  state  that,  in  my  mind,  no  good  grounds  have 
as  yet  been  given  for  the  division  of  alopecia  areata  into  forms  depending  upon  the 
extent  of  area  affected;  for,  apparently,  at  least,  the  aetiology,  method  of  extension  and 
condition  of  the  parts  affected,  judging  from  the  clinical  history,  are  similar,  whether 
the  disease  remains  confined  to  a single  small  spot,  or  whether  there  are  several  circum- 
scribed patches  of  various  size,  or,  finally,  whether  the  entire  body  becomes  hairless. 

Gruby,  Malassez,  Eichliorst,  Thin,  Buchner,  Lassarand  Yon  Sehleu  may  be  regarded 
as  the  principal  observers  who  have  endeavored  by  their  studies  and  arguments  to  prove 
its  origin  from  organisms. 

As  it  has  long  been  decided  by  subsequent  observers  that  the  fungus  described  by 
Gruby*  is  the  trichophyton  tonsurans,  and  that  by  Malassez  f is  an  organism  acci- 
dentally but  not  very  infrequently  found  on  the  skin,  with  no  relation  whatever  to  the 
disease,  alopecia  areata,  I will  pass  on  to  a consideration  of  the  observations  and  deduc- 
tions of  the  other  observers  mentioned. 

Eichhorst  f found  spores  in  diseased  hairs  once  in  nine  cases.  They  were  situated 
between  the  hair  and  root  sheath,  did  not  color  in  Bismarck  brown,  and  consisted  of 
round  elements  of  a yellowish-brown  color,  variable  in  size,  the  smallest  appearing  as 


* Gruby.  “ Recherchcs  sur  la  Nature,  lo  Sifige,  et  lo  Developpoment  du  Porrigo  Decalvans  ou 
Phytoalopeeie.”  Compt.  rend,  de  V Acad,  des  Sc.,  1843. 

t Malassez.  “ Note  sur  lo  Champignon  do  la  Pelade.”  Arch,  de  Phijs.  Norm,  et  Path.,  1S74, 
r,  203. 

\ Eichhorst.  “ Beobaohtungen  iiber  Area  Celsi.”  Virch.  Arch.,  Bd.  78,  vm,  p.  197-209. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY.  243 


shining,  homogeneous  bodies,  and  the  larger  ones  somewhat  like  red  blood  corpuscles, 
with  light  double  contour.  In  the  latter,  a small,  shining,  transparent  body  was  often 
seen.  The  usual  seat  of  the  spores  was  between  the  hair  and  inner  root  sheath,  hut  an 
occasional  one  was  observed  between  the  epithelial  cells  of  the  root  sheath.  .Spores 
were  found  ou  the  hair  as  far  as  the  root  sheath  remained  connected  with  the  shaft,  that 
is,  in  the  upper  two-thirds  of  the  hair  follicle.  Mycelia  were  not  found.  He  thought 
that  the  fungus  was  related  to  that  of  tinea  versicolor. 

Buchner  (H.)  * believes  that  the  disease  is  parasitic,  although  he  was  unable  to 
detect  a special  fungus,  hie  suggests  the  small  size  of  the  organism  or  imperfect  lenses 
as  possible  cause  for  the  rarity  of  detection  by  observers  of  the  fungus;  and  adds  the 
fact  that  it  is  possible  that  single  celled,  non-colonized  •rganisins  can  be  present,  yet 
indistinguishable  from  lifeless  granules,  or  be  hidden  from  observation  by  the  tissues. 
He  tried  cultivation  in  one  case,  and  in  eight  experiments  always  found  the  same 
fungus,  a form  of  organism  never  observed  by  him  as  accidentally  occurring  in  the  hair. 
It  consisted  of  small,  shining,  sharply-limited  granules,  with  two  fine,  thread-like  pro- 
jections in  opposite  directions.  He  does  not,  however,  maintain  that  this  fungus  is  with 
certainty  the  one  causing  alopecia.  Regarding  the  symptoms,  he  thinks  that  the  method 
of  spreading  of  the  disease  is  a sufficient  proof  that  it  is  parasitic  in  its  nature. 

Dr.  Thin  (Geo.)  f found  small,  shining  bodies,  which  from  their  arrangement  and 
other  qualities  he  believes  to  be  organisms,  in  the  hair  shaft  and  between  the  shaft  and 
the  hair  sheaths.  He  believes  that  the  fungus  enters  the  hair  follicle  between  the 
internal  root  sheath  and  the  shaft,  and  toward  the  root  of  the  hair  penetrates  the  hair 
substance,  and  as  it  multiplies,  ascends  upward  in  the  hair,  breaking  it  up  and  loosen- 
ing it. 

Von  Sehlen  J colored  his  preparations  by  a special  method,  and  also  made  cultures 
of  certain  organisms  which  he  saw.  He  found  micrococci,  especially  in  the  outer  part 
of  the  follicle,  above  the  sebaceous  gland  opening,  but  also  as  low  down  as  the  papilla 
in  some  cases.  They  were  not  found  in  all  hairs,  but  mostly  in  those  with  retained 
root  sheaths.  His  drawings  show  the  presence  of  micrococci  without  doubt,  and  in 
colonies.  He  made  cultures  and  inoculations,  but  although  a falling  out  of  hair  was 
observed  to  follow  the  inoculations,  the  course  of  the  disease  thus  experimentally  pro- 
duced did  not  very  closely  resemble  that  of  alopecia  areata. 

Other  observers  have  written  upon  the  subject  and  described  organisms  in  the  hair 
follicles,  but  as  their  observations  give  us  no  more  proof  than  those  already  quoted,  it 
is  not  necessary  to  refer  to  them,  as  the  same  arguments  to  be  used  against  the  above 
observations  will  hold  good  for  these  also. 

Before  considering  the  value  of  these  observations,  it  will  be  necessary  to  bear  in 
mind  the  symptoms  and  clinical  history  of  the  disease,  and  to  these  I will  now  briefly 
draw  your  attention. 

As  a rule,  no  subjective  symptoms  of  any  kind  mark  its  onset;  sometimes  it  is  pre- 
ceded by  neuralgic  pains  or  a sense  of  slight  burning  or  itching  of  the  part  from  which 
the  hair  is  about  to  fall  out.  The  patient  may  notice  for  several  days  that  his  hair  is 
falling  out,  and  soon  a bald  spot  is  observed;  or  a large  spot  may  form  very  quickly. 


* Buchner.  Ueber  Pilze  bei  Area  Celsi  : Sitzung  d.  arztl.  Vereins  in  Miinchen.  Kritische 
Bemerkungen  zur  Aetiologie  der  Area  Celsi.  Archiv  f.  pathol.  Anatom.,  1878,  Bd.  71,  p.  527. 

t Thin.  “On  Bacterium  Decalvans;  an  organism  associated  with  the  Destruction  of  the  Hair 
in  Alopecia  Areata.”  Proceedings  of  the  Royal  Soc.,  Lond.,  xxxm,  1881,  No.  217.  “Alopecia 
Areata  and  Bacterium  Decalvans.”  Monatsch.  f.  prakt.  Dcrmat.,  1885,  8,  p.  241. 

J Von  Sehlen.  “ Zur  Aetiologie  der  Alopecia  Areata.”  Virch.  Arch.,  Bd.  99,  p.  327.  “ Mikro- 
kokken  bei  Area  Celsi.”  Fortsch.  d.  Medic.,  1883,  23,  p.  763.  “ Zur  Aetiologie  der  Alopecia 

Areata.”  Aerzt.  Intelligbl.,  No.  28,  p.  317. 


244 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  bald  spots  are  more  or  less  circular  in  outline,  are  usually  at  first  quite  small, 
but  may  gradually  increase  until  a large  surface  is  covered.  They  increase  in  size  by 
extension  at  the  periphery,  and  may  remain  small  or  cover  a very  large  area.  The 
patch  devoid  of  hair,  whether  large  or  small,  is  smooth,  shining,  pale,  sunken  beneath 
the  general  surface;  the  hair  at  the  margin  of  the  patch  is  thinner  than  normal  and 
comes  out  with  a very  moderate  amount  of  traction.  A certain  number  of  broken-off 
hairs  are  frequently  present.  There  is  no  redness  or  scaling  to  be  observed,  and  usually 
all  the  hairs  within  the  bald  area  fall  out.  There  may  be  only  one  spot  or  many;  when 
the  latter  is  the  case,  they  arise  successively,  and  even  some  spots  may  heal  while  new 
ones  arise.  After  existing  for  a variable  time,  usually  several  months,  the  disease 
frequently  disappears  spontaneously;  in  other  cases  permanent  alopecia  results,  without 
giving  rise  to  any  change  in  the  existing  characters  of  the  patch.  The  hairs  which  fall 
out  show  signs  of  interference  with  the  nutrition  of  the  whole  hair,  and  not  a local 
interference,  as  in  ringworm. 

Sections  of  the  skin  have  been  examined  by  Schultze,* * * §  E.  Wagner,  f and  Duckworth 
and  Harris.  % The  two  former  found  no  changes  whatever.  The  latter,  in  sections 
stained  with  haematoxylon,  found  atrophy  of  the  hair  follicles,  these  appearing  as  long, 
fibrous  cords  ; considerable  increase  in  the  connective  tissue  in  the  neighborhood  of  the 
atrophied  follicles,  but  not  elsewhere  ; almost  entire  absence  of  the  sebaceous  glands  ; 
sweat  glands  normal  ; infiltration  of  the  hair  follicles,  especially  of  their  outer  sheath, 
with  a new  round-celled  growth.  In  some  instances  remains  of  hair  papillae  were  seen  ; 
but  the  papillary  loops  were  infiltrated  with  the  round  cell  growth.  No  parasitic  ele- 
ments were  found  ; but  as  they  stained  the  sections  with  haematoxylon  only,  their  nega- 
tive observation  is  of  no  value  whatever.  The  absence  of  any  statement  as  to  the 
duration  of  the  disease,  and  as  to  the  previous  treatment,  detracts  much  from  the  value 
of  the  case  studied  by  them  ; but  from  the  absence  of  the  sebaceous  glands,  and  the 
new  connective  tissue  formation,  it  was  very  likely  oue  of  long  standing. 

The  portions  of  the  clinical  history  to  which  I wish  especially  to  refer,  are  the 
manner  of  origin  and  spreading  of  the  patches,  the  absence  of  superficial  inflammatory 
symptoms  iu  almost  every  case,  the  almost  complete  filling  out  of  hair  in  a given  area, 
the  rarity  of  signs  of  local  interference  with  nutrition  of  the  hair  shaft,  the  irregular 
duration  of  existence  of  the  spots,  the  size  of  different  patches,  and  the  usually  finally 
complete  restoration  to  a normal  condition. 

As  the  upholders  of  the  parasitic  theory  all  describe  the  fungus  as  situated  either  in 
the  hair  follicle,  hair  shaft,  or  corneous  layer,  we  must  first  consider  what  effects  are 
produced  by  organisms  present  upon  or  within  the  living  or  dead  tissues. 

As  shown  by  Bizzozero  $ and  others,  many  organisms  are  constantly  present  on  the 
normal  skin,  not  acting  upon  the  living  tissues  or  taking  their  nourishment  from  them, 
but  living  upon  the  dead  material,  the  product  of  secretion  and  desquamation.  As  this 
latter  is  inert  matter  it  is  incapable  of  reacting  from  the  presence  of  these  fungi,  con- 
sequently there  are  no  signs  of  interference  with  nutrition.  In  the  living  tissues  fungi 
can  produce  tissue  growth  or  degeneration,  or  cause  inflammatory  action,  varying  in 
intensity  from  a slight  nutritive  change  to  suppuration  or  necrosis  ; or  can  act  injuriously 
upon  the  normal  nutritive  processes  of  the  part  by  abstracting  nourishment  from  the 


* Schultze.  “Die  Theorien  iibor  Area  Celsi.”  Virch.  Arch.,  1880,  Bd.  80,  p.  193. 

j"  Wagner.  Arch . f.  ph i/a.  Heillcunde,  1859. 

J Duckworth  and  Harris.  “Case  of  Area  Celsi,  in  which  the  parts  were  examined  after  death." 
Transactions  Path.  Soc.,  Lonrl.,  1882,  p.  386. 

§ Bizzozero.  “Ucberdio  Microphyten  der  normalen  Oberhaut  des  Menschen.’’  Virch.  Arch., 
Bd.  98,  p.  451. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


245 


tissues,  either  directly  or  by  the  plugging  of  vessels,  or  by  the  organisms  or  the  produc- 
tion of  a fibrinous  coagulum  within  the  latter. 

The  upholders  of  the  parasitic  theory  claim  that  the  manner  of  spreading  of  the 
eruption,  the  occasional  redness  or  slight  scaling  observed,  the  presence  of  broken  hairs, 
the  presence  of  organisms,  the  occasional  contagious  character,  as  apparently  shown  by 
reported  cases,  and  the  results  of  treatment,  fairly  prove  the  correctness  of  their  view, 
at  the  same  time  that  they  disprove  the  theory  of  a neurotic  origin. 

First  as  regards  the  manner  of  spreading.  Every  one  will  admit  that  the  manner  in 
which  the  patches  increase  in  area,  viz.,  by  contiguity  of  tissue,  thus  producing  more 
or  less  circular  areas  of  baldness,  is  such  as  to  lead  us  to  strongly  suspect  a parasitic 
affection,  even  if  a fungus  be  not  found,  as  this  manner  of  spreading  is  the  rule  with 
local  parasitic  affections.  Buchner  even  declares  that  it  is  absurd  to  suppose  that  an 
affection  of  the  nerves  or  blood  vessels  can  give  rise  to  such  spreading  areas  as  occur  iu 
alopecia  areata.  As  will  be  shown  later  on,  however,  Scliultze  endeavors  to  show  that 
it  is  compatible  with  the  neurotic  theory,  and  the  recent  experiments  of  Joseph,  to 
which  I will  presently  refer,  seem  to  confirm  his  statements.  Nevertheless,  the  fact 
that  all  the  spots  spread  in  the  same  manner,  although  not  conclusive,  is  a strong  point 
in  favor  of  the  parasitic  theory,  on  the  grounds  already  mentioned,  and  should  have  its 
value  as  rather  favorable  evidence. 

As  regards  the  method  of  falling  out  of  the  hairs,  it  seems  to  point  rather  against 
than  for  the  cause  consisting  in  organisms,  existing  either  on  the  general  surface  or  in 
the  hair  follicles.  Thus  not  infrequently  a patient  finds  that  quite  a large  patch  of 
baldness  has  evidently  formed  in  a very  short  period  of  time,  waking  up  in  the  morning, 
as  they  say,  to  find  a bald  spot,  the  first  intimation  they  have  had  of  their  having  any 
disease  of  the  scalp.  If  the  disease  depends  upon  such  organisms  as  have  been  described, 
organisms  so  difficult  to  find  on  account  of  their  small  number  rather  than  their  diminu- 
tive size,  one  would  not  expect  such  rapidly  forming  areas  of  baldness,  certainly  not 
without  being  accompanied  by  more  inflammatory  symptoms  than  are  observed.  So 
also  the  usually  complete  falling  out  of  hairs  in  the  affected  area  is  to  my  mind  opposed 
to  the  view  of  the  fungus  having  its  seat  in  the  hair  follicles  alone , for  then,  as  the  disease 
spreads,  many  hairs  would  probably  escape  invasion,  and  there  would  merely  be  thinning 
of  hair.  If  the  fungus  lived  in  hair  follicles,  and  on  dead  epidermis  of  the  corneous  layer, 
as  in  ringworm,  then  we  could  have  all  the  hairs  affected  as  the  fungus  invaded  contiguous 
elements.  But  in  this  case  what  would  we  discover?  No  doubt  just  what  is  seen  in 
ringworm,  viz.,  signs  of  inflammation  or  interference  with  nutrition,  or  else  no  change 
in  the  hair,  as  iu  tinea  versicolor  ; that  is,  there  would  be  a large  number  of  broken  off 
hairs  caused  by  a fungus  at  the  seat  of  fracture,  and  signs  of  inflammation,  or  there 
would  be  no  interference  with  the  nutrition  of  the  part  invaded.  We  find,  however,  iu 
alopecia,  that  the  majority  of  the  hairs  fall  out  entire,  accompanied  frequently  with  the 
root  sheaths,  the  shafts  showing  signs  of  atrophy,  which  I need  not  here  describe,  as 
they  are  not  those  which  bear  any  resemblance  to  what  would  be  expected  from  the  local 
action  of  an  organism.  If  the  organisms  were  situated  at  the  base  of  the  follicle,  they 
-could,  of  course,  possibly  deprive  the  hair  of  its  proper  nourishment,  if  present  in  great 
numbers,  by  abstracting  it  from  the  follicle  sheath  region  for  themselves  ; but  then  they 
would  be  in  living  tissue  and  would  probably  give  rise  to  inflammatory  changes,  and 
should  be  easily  detected  by  microscopical  examination.  According  to  Duckworth  and 
Harris,  already  quoted,  inflammatory  changes  were  observed  in  sections  from  their  case, 
but  they  found  no  fungus.  I have  already  drawn  attention  to  the  incompleteness  of  the 
history  of  that  case,  and  consequent  difficulty  of  properly  estimating  the  value  of  the 
histological  changes  observed,  as  the  inflammation  may  have  been  produced  by  external 
applications  for  the  cure  of  the  disease. 


246 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Theu  as  regards  the  broken  off  hairs  to  he  observed  in  greater  or  less  number, 
although  the  number  is  frequently  very  small,  in  the  majority  of  cases  no  fungi  are  to 
be  detected  at  the  seat  of  fracture.  Furthermore,  the  condition  of  the  hair  in  its  imme- 
diate neighborhood  is  not  such  as  to  suggest  the  disintegration  of  fibres  from  organisms, 
neither,  as  far  as  I am  aware,  have  organisms  been  found  at  that  part.  While,  there- 
fore, the  method  of  spreading  of  the  patches  favors  the  parasitic  theory,  the  manner  of 
falling  out  of  the  hairs  and  their  anatomical  condition,  oppose  the  idea  of  the  presence 
of  a fungus  within  them  and  acting  injuriously  upon  their  structures.  The  possibility 
of  a fungus*existing  in  the  living  tissue  at  the  base  of  the  follicle  is  not,  however, 
excluded;  but  that  is  not  the  situation  which  has  been  given  by  any  one,  except  Dr. 
Thin,  as  the  seat  of  the  organism,  but  rather  the  part  of  the  follicle  above  the  place 
where  the  sebaceous  gland  duct  enters  it.  The  above  criticism  is,  therefore,  especially 
opposed  to  the  conclusions  of  Yon  Sehlen,  and  those  who  think  the  fungus  is  situated 
upon  the  general  surface  or  within  the  upper  part  of  the  follicle. 

That  occasionally,  even  if  very  rarely,  there  is  some  redness  or  slight  itching  or 
scaliness  observed  at  the  commencement  of  the  disease,  would  show  some  inflammation 
with  a probable  local  cause;  but  as  this  redness  is  an  exceptional  condition,  and  further- 
more, does  not  persist  with  the  continuance  of  extension  of  the  eruption,  it  can  scarcely 
be  considered  to  fie  the  result  of  organisms  such  as  have  been  described,  even  if  we  do- 
not  forget  that  a patch  of  ringworm  sometimes  shows  no  signs  of  inflammation. 

We  will  now  consider  the  situation  of  the  organisms,  as  described  by  the  authors 
already  mentioned,  and  the  proof  of  their  setiological  connection  with  alopecia. 

Gruby  found  them  surrounding  the  hair  shafts,  but  his  cases  were  evidently  exam- 
ples of  ringworm.  Malassez  found  them  only  in  the  most  superficial  layers  of  the 
epidermis,  and  never  in  the  hair  follicles.  The  organisms  described  by  him  are  con- 
sidered, probably  by  all  who  have  worked  upon  the  subject,  as  accidental  organisms, 
having  no  pathological  significance  for  the  tissues  of  the  scalp.  Buchner  found  n» 
thngus  for  certain  except  after  cultivation  of  hairs.  Eichhorst  found  once  in  nine  cases 
a fungus  between  hair  and  root  sheath,  having  some  resemblance,  according  to  him, 
to  the  fungus  of  tinea  versicolor.  These  four  observers  all  describe  a different  organ- 
ism, and  all  have  failed  to  show  the  slightest  relationship  between  the  fungus  and  the 
alopecia.  As  regards  Eichhorst’s  fungus,  on  account  of  its  size  there  should  have  been 
no  difficulty  in  detecting  it  in  every  case  of  the  disease,  if  it  was  a constant  element 
and  the  cause  of  the  disease.  As  he  found  it  only  once  in  nine  cases,  we  can  dismiss 
the  observation  as  being  valueless  in  the  question  of  aetiology. 

There  remain  still  for  consideration  the  studies  of  Dr.  Thin  and  Yon  Sehlen. 

Dr.  Thin  found  the  elements  which  he  considered  to  be  bacteria,  in  the  situations 
already  described,  and  attributed  to  the  growing  organisms  the  loosening  and  falling 
out  of  the  hairs.  He  did  not  stain  the  bodies  he  saw,  or  make  cultures  and  inocula- 
tions. The  objections  to  the  conclusions  are  that  the  hairs,  as  a rule,  do  not  show  signs 
of  breaking  up  and  disintegration,  such  as  would  be  produced  by  a fungus  growing 
within  them.  It  is  not  necessary  to  repeat  the  observations  of  Hutchinson*  (J. ), 
Michelson,  Rindfleisch,f  Kaposi,  J SchultzeJ  and  others,  all  of  which  tend  to  show 
that  the  splitting  up  or  fibrillation  of  the  hair  shafts,  which  sometimes  occurs,  is  the 
result  of  an  atrophy  from  interference  with  the  factors  engaged  in  hair  production,  and 
not  from  direct  action  of  an  agent  upon  the  hair  structure,  after  its  formation  is  coiu- 


* J.  Hutchinson’s  “ Roport  on  the  Natiiral  History,  Diagnosis  and  Troatment  of  Alopecia 
Circumscripta.”  London  Medical  Times  and  Gazette,  1852,  I,  page  165. 

j- Michelson,  Rindfleisch.  “ Area  Celsi.”  Arch.  f.  Dermatol,  und  Syph.,  Prag,  1S69,  i,  p. 
483. 

J Kaposi.  “ Pathologic  und  Therapio  der  Hautkrankheiten,”  1880.  § Schultze.  Ibid . 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


247 


pleted.  It  can  be  argued  that  the  deductions  from  these  observations  are  not  correct, 
and  that  the  fatty  degeneration,  the  longitudinal  fibrillation,  or  transverse  fractures 
observed,  are  the  result  of  interference  with  the  hair  structure.  As  these  nutritive 
changes  are  found  in  only  a small  proportion  of  the  hairs  of  an  affected  area,  and  organ- 
isms have  not  been  invariably  found  at  the  seat  of  fracture,  while  the  majority  of  the 
hairs  have  an  unchanged  consistence  and  show  none  of  these  breaking-up  changes,  the 
loose  hairs,  accompanied  with  or  without  their  root  sheaths,  having  the  hair  root  usually 
thin  and  pointed  and  pale  in  color,  while  the  upper  part  of  the  hair  is  larger  and  darker, 
and  the  free  end  fibrous  or  brush-like  in  character,  these  deductions  may  be  considered 
justifiable.  Schultze  found  that  the  splitting  up  of  ripe  hairs  appears  only  on  certain 
parts  of  the  shaft,  the  best  examples  occurring  in  dry  atrophic  hairs,  poor  in  pigment, 
and  in  a stage  of  “Sclialt”  or  “ Beeth  ” hair  condition.  In  these  cases  a frequent 
absence  of  the  root  sheath  and  of  the  normal  hair  cuticula  favors  splitting  of  the  shaft. 
The  medulla  is  frequently  absent.  These,  together  with  the  other  changes  which  have 
been  described  by  observers,  make  the  seat  of  origin  of  the  nutrition  changes  not 
within,  but  outside  of  the  follicle,  i.  e.,  in  the  factors  concerned  in  hair  production. 
Still,  as  already  mentioned,  organisms  might  be  situated  within  the  follicle,  and,  by 
abstracting  or  taking  up  the  nourishment  intended  for  the  hair  growth,  produce  the 
falling  out  of  the  hair.  They  are,  however,  not  found  in  the  ordinary  atrophied  hairs, 
or  in  hairs  not  yet  loose;  and  other  observers  have  very  rarely  found  organisms  in  the 
lower  part  of  the  follicle;  and,  furthermore,  if  they  were  confined  exclusively  to  the 
lower  part  of  the  follicle,  not  existing  upon  ordinary  dead  epidermis,  the  patches  would 
not  be  round  in  form,  since  for  this  to  occur  the  organisms,  if  on  the  exterior  of  the 
body,  must  be  able  to  exist  on  the  general  surface — the  corneous  layer,  to  produce  a 
regular  spreading  patch.  On  these  grounds  we  must  conclude  that  no  connection  has 
been  shown,  from  a clinical  or  histological  standpoint,  to  exist  between  the  elements 
described  by  Dr.  Thin  and  the  disease  alopecia  areata,  although  some  of  the  changes 
observed  in  the  broken  hairs  may  be  caused  by  the  organisms  described  by  him. 

Von  Sehlen,*  whose  work  drew  renewed  attention  to  the  aetiology  of  this  disease,  dis- 
covered micrococci  organisms  in  considerable  numbers,  situated  principally  in  the  hair 
follicles,  above  the  place  where  the  sebaceous  gland  duct  enters  the  follicle.  They  were 
not  found  in  all  hairs,  but  mostly  in  those  with  retained  root  sheaths  after  epilation, 
and  possessed  sufficient  distinctive  characters  for  other  observers  to  substantiate  his 
observations.  He  also  made  cultures  and  inoculations,  with  the  result  of  causing  a loss 
of  hair  in  the  part  subjected  to  the  experiment,  although  the  hair  did  not  fall  out  in 
the  manner  peculiar  to  alopecia  areata. 

From  these  observations,  then,  we  learn  that  a certain  organism  is  very  generally 
present,  but,  as  already  shown,  organisms  upon  the  general  surface,  or  at  the  openings 
of  hair  follicles,  cannot  produce  the  symptoms  of  this  disease.  That  inoculations  fail 
is  to  my  mind  no  proof  against  its  parasitic  nature,  for  the  tissues  in  the  animals 
experimented  on  may  not  have  been  favorable  for  their  growth.  The  fatal  objection, 
however,  to  these  organisms  having  any  tetiological  connection  with  alopecia  is  that 
Bizzozero.t  Bordoni-Uffred  uzzi.j  Michelson  'b,  and  others  maintain  that  they  have  found 
a similar  fungus  under  normal  conditions,  that  they  have  cultivated  this  fungus  and 


fBizzozero.  Ibid. 

\ Bordoni-Uffreduzzi.  “Uebcr  die  biologischen  Eigenschaften  der  normalen  Ilautmikropby- 
ten.”  Fortschr.  d.  Mediz,  1886,  No.  5. 

$ Michelson.  Fortschritte  d.  Med.,  1886,  No.  7,  p.  230.  “Ueber  die  sogen.  Area.  Kokkcn.” 
Virchow’s  Archiv,  1885,  Bd.  99,  p.  572.  Bcmerkung  zu  den  Arbeitcn  des  Ilerrn.  Dr.  von  Sehlen 
“ iiber  die  Aetiologie  der  Alopecia  Areata.  Zur  Discussion  iiber  die  Aetiologie  der  area  celsi.” 
Virch.  Arch.,  1880,  Bd.  80. 


248 


NINTI-I  INTERNATIONAL  MEDICAL  CONGRESS. 


made  inoculations,  with  the  result  that,  if  much  material  was  used,  signs  of  inflamma- 
tion were  produced. 

Beuder  * found  similar  organisms  to  Yon  Sehlen’s  in  all  his  seven  cases  but  one,  and 
also  in  the  normal  scalp,  and  made  cultures  and  inoculations,  but  with  negative 
results. 

Bordoni-Uffreduzzi  thinks  these  organisms  are  normal  to  the  part.  He  made  inocu- 
lations after  cultivation,  and  if  many  organisms  were  used  the  scalp  was  irritated, 
while  if  there  were  only  a few  no  signs  of  inflammation  appeared.  He  examined 
hairs  from  the  normal  scalp  of  himself  and  others,  and  found  micrococci  colonies  of 
similar  appearance  as  those  described  by  Von  Sehlen. 

These  observations  and  experiments  by  inoculation  strengthen  the  arguments  which 
I used  against  the  cause  of  the  disease  being  any  organism  on  the  general  surface,  or 
within  the  hair  follicle,  on  account  of  the  absence  of  signs  of  inflammation. 

Yon  Sehlen  denies  the  correctness  of  the  observations  of  his  opponents,  and  I think 
we  should  not  forget  that  previous  to  the  time  Von  Sehlen  described  these  organisms, 
organisms  present  in  considerable  numbers,  some  of  these  observers  stoutly  denied  the 
existence  of  fungi  of  any  kind  on  the  scalp  in  Alopecia  areata,  showing  surely  that  they 
were  not  very  careful  observers. 

If  the  disease  is  parasitic  and  the  organism  situated  in  the  parts  described  by  Von 
Sehlen,  anti-parasitic  remedies  should  almost  invariably  and  quickly  control  the  disease. 
As  the  inoculation  experiments  were  unsuccessful  ; as  similar  organisms  have  been 
found  in  normal  skin;  as  the  situation  of  the  fungus  is  such  that  the  production  of  hair 
would  not  be  interfered  with;  as  inflammatory  symptoms  are  absent,  and  anti-parasitic 
treatment  frequently  unsuccessful,  we  cannot  admit  that  Von  Sehlen  has  proven  his 
view,  or  even  made  it  probably  a correct  one. 

As  regards  the  contagiousness  of  the  disease,  although  some  cases  have  been  reported 
which  would  suggest  its  contagious  nature,  yet  the  disease  may  be  regarded  as  non-con- 
tagious in  the  ordinary  sense  of  the  word.  In  Hutchinson’s  forty-two  cases  no  two 
occurred  in  members  of  the  same  family  or  playmates.  Experiments  by  inoculation 
from  head  to  head,  and  upon  places  of  a scalp  of  a person  already  atfected,  have  always 
given  negative  results,  so  that  the  upholders  of  the  parasitic  theory  receive  no  support 
on  this  point,  but  rather  the  opposite.  I believe,  however,  that  we  should  not  lay  much 
stress  upon  the  absence  of  proved  contagion.  Alopecia  is  a rare  disease,  and  conse- 
quently if  it  is  parasitic,  the  ground  is  rarely  in  a favorable  condition  for  the 
growth  of  the  organism  ; hence  failure  of  inoculation  is  no  proof  of  its  non-parasitic 
nature.  We  know  how  numerous  the  organisms  are  in  tinea  versicolor,  and  that  fur- 
thermore they  live  upon  the  very  surface,  a situation  most  favorable  for  contagion,  yet 
the  disease  is  not  a contagious  one  clinically  speaking.  The  same  is  true  of  tubercu- 
losis, and  even  in  such  a severe  disease  as  osteo-myelitis  organisms  injected  into  the  sys- 
tem have  failed  to  induce  the  disease  until  the  bones  were  previously  injured.  All  this 
goes  to  show  that  absence  of  frequent  examples  of  contagion  is  no  proof  of  a disease 
not  being  parasitic  in  its  nature.  At  the  same  time,  the  few  cases  of  alopecia  reported 
as  showing  its  contagiousness  should  not  be  regarded  as  of  much  value  when  the  non- 
contagious  character  is  generally  so  evident. 

When  we  come  to  study  the  treatment  recommended,  it  is  to  be  observed  that  reme- 
dies that  are  anti-parasitic  in  their  action  are  the  only  ones  recommended ; and,  according 
to  the  latest  views,  such  remedies  as  corrosive  sublimate  and  sulphur  are  positive  in 
their  effects  That  the  disease  has  a tendency  to  disappear  spontaneously  and  at  very 
uncertain  periods  of  its  existence,  interferes  considerably  with  our  ability  to  judge  of 


* Bender.  “ Ueber  die  Aetiologio  der  Alopecia  Areata.”  Deittach.  Med.  Wochenachri/t,  Berlin, 
1886,  xii,  p.  817. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


249 


the  results  of  treatment  in  single  cases  ; but  when  a large  number  have  been  treated 
by  anti-parasitic  remedies  with  uniform  success,  as  in  the  fifteen  cases  reported  by  Dr. 
Thin,*  we  are  justified  in  attributing  the  result  to  the  remedy.  It  has  been  maintained 
that  all  these  remedies  are  more  or  less  irritant  in  their  action  also,  and  that,  perhaps, 
it  is  to  this  quality  that  any  beneficial  effect  is  due.  Irritating  applications,  as  blister- 
ing, or  croton  oil  of  a strength  sufficient  to  produce  marked  dermatitis,  have  been  em- 
ployed exclusively  by  some,  and  these  applications  continued  for  weeks  if  necessary. 
Those  who  have  treated  cases  in  this  manner  must  have  observed  very  often  favorable 
results;  but  such  results  do  not  show  the  disease  to  be  non-parasitic;  for  do  we  not  use 
the  same  means  sometimes  to  cure  inveterate  cases  of  tinea  tonsurans  ? So,  also,  the 
fact  that  many  cases  resist  the  use  of  anti-parasitic  remedies  is  not  a proof  that  organ- 
isms do  not  cause  the  disease.  How  many  cases  of  ringworm  resist  treatment  for 
months  and  months,  although  the  fungus  is  situated  in  not  very  inaccessible  regions ; 
and  if  the  organisms  are  deeper  seated,  as  in  lupus  vulgaris,  anti-parasitic  applications 
are  of  but  little  value,  indeed.  Then,  further,  it  does  not  follow  that  if  an  organism 
is  the  cause  of  the  disease,  it  is  still  present  in  old,  non-spreading  areas,  no  more 
than  the  fungus  of  favus,  for  instance,  is  present,  because  we  see  the  results  of  its  action 
in  permanent  alopecia.  It  may  have  been  present  and  produced  directly  or  indirectly 
the  changes  which  led  to  the  alopecia  areata;  and  the  nutritive  disturbances  continue 
indefinitely,  although  the  organism  has  long  ceased  to  be  present.  In  that  case,  anti- 
parasitic  remedies  as  such  could  have  no  effect.  To  judge  of  their  value,  then,  they 
should  be  used  in  an  early  stage  of  the  disease,  or  while  the  alopecia  spot  is  increasing 
in  size;  and  in  these  cases  they  have  been  found  to  be  very  frequently  of  benefit  by 
many  observers,  while,  according  to  Lassar  f and  Thin,  their  action  is  prompt,  positive 
and  decided. 

To  sum  up  the  results  of  treatment,  we  find  that  remedies  anti-parasitic  in  their 
action  are  the  most  certain  means  we  possess  at  present  for  the  treatment  of  alopecia 
areata,  although  they  are  not  always  to  be  relied  upon. 

We  have  thus  seen  that  the  absence  of  signs  of  superficial  inflammation,  the  char- 
acter of  the  falling  out  hairs,  the  negative  results  of  inoculation  of  the  cultured  organ- 
isms observed,  the  apparently  non-contagious  nature  of  the  disease,  and  the  frequent 
failure  in  treatment  of  anti-parasitic  remedies,  render  it  fairly  certain  that  the  disease 
does  not  depend  upon  organisms  situated  either  upon  the  general  surface  or  within  the 
hair  follicles.  The  finding  of  organisms  in  these  situations  is  of  itself  no  proof  what- 
ever of  an  aetiological  relationship  to  the  disease,  for  Bizzozero  and  others  have  shown 
that  many  forms  exist  upon  the  normal  scalp. 

The  upholders  of  the  neurotic  theory  have,  until  lately,  depended  principally  upon 
the  clinical  symptoms,  and  the  failure  of  observers  to  show  an  organism  having  an  aetio- 
logical relation  to  the  disease. 

The  clinical  symptoms  which  they  believe  point  to  a neurosis  are  1st,  changed  sen- 
sibility of  the  part;  2d,  neuralgic  symptoms  appearing  before  or  during  the  disease; 
3d,  heredity.  They  further  support  their  view  of  the  significance  of  these  symptoms, 
by  inferences  from  comparisons  with  other  diseases  of  a known  neurotic  character,  in 
which  there  is  falling  out  of  hair,  and  from  experiments  which  show  that  alopecia  can 
be  produced  at  will  by  injury  to  certain  parts  of  the  nervous  system. 

We  will  pass  rapidly  over  the  arguments  for  the  neurotic  origin,  with  the  exception 
of  the  experiments  of  Joseph;  for,  as  Michelson  justifiably  wrote  before  these  experi- 


* Thin.  “Alopecia  Areata.”  Br.  Med.  Jour.,  1882,  u,  783.  “ A further  contribution  to  the 
Treatment  of  Alopecia  Areata.”  Brit.  Med.  Journ.,  1882,  ir,  828. 

f Lassar.  “ Die  Uebertragbarkeit  der  Alopecia  praematura.”  Monatachr.  f. pr.  Derm.,  1882, 
p.  131.  Deut.  Med.  Wochenachft.,  1885,  p.  531. 


250 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ments  were  made,  “dass  auch  dieser  Theorie  (der  neurotischen)  bei  dem  derzeitigen 
Stand  der  Wissenschaft  eine  solide  Basis  noch  durchaus  fehlt.” 

Michelson  * * * § found  tactile  sensation,  electro  cutaneous  sensibility,  pressure  and  tem- 
perature sense  unchanged,  sometimes  even  increased.  The  absence  of  perverted  sensi- 
bility, however,  is  not  against  a nervous  origin,  as  in  Joseph’s  experiments  there  was 
no  change  in  the  sensibility  of  the  part.  Hence,  the  argument  of  a changed  sensibility 
in  the  part  has  no  decided  value. 

That  neuralgia  frequently  precedes  or  accompanies  the  disease  is  an  accepted  fact; 
but  alopecia  areata  also  frequently  occurs  without  antecedent  or  present  nervous  symp- 
toms. Collier  f reports  a case  of  a boy  who  was  struck  with  the  fist  over  the  left  ear, 
causing  intense  neuralgia,  lasting  two  weeks;  it  then  ceased  and  was  followed  by  alopecia 
areata  of  the  left  parietal  region.  In  Mr.  Hutchinson’s  forty-two  cases  only  four  com- 
plained of  severe  headaches.  Cases  have  been  reported  of  the  headache  ceasing  when 
the  hair  had  fallen  out.  But  the  number  of  cases  accompanied  or  preceded  by  neural- 
gic symptoms  is  too  few  to  justify  tis  in  attaching  any  special  importance  to  the  condi- 
tion, at  least  in  the  sense  of  cause  and  effect. 

The  argument  of  deduction  from  analogy  by  observation  of  certain  nervous  dis- 
turbances producing  alopecia  is  of  more  value.  A few  examples  will  suffice. 

Dr.  Crocker  reports  a case  of  a boy  who  fell  upon  his  head,  and  soon  became  com- 
pletely and  permanently  hairless.  Kinney  j:  reports  a case  of  general  alopecia  six  to 
eight  days  after  a shock  caused  by  lightning  striking  a tree  near  the  patient.  Unna  \ 
reports  a case  in  which  epilepsy,  hemicrania,  Graves’  disease  and  alopecia  areata  all 
appeared  simultaneously  after  a severe  fright. 

Fredet  ||  reports  a case  of  a female,  age  seventeen,  of  previous  good  health,  who  was 
sitting  at  a window  when  the  floor  fell  in.  She  caught  hold  of  the  window  frame,  and 
held  on  till  released.  No  loss  of  consciousness  or  nervousness  followed.  On  the  follow- 
ing night  she  had  headache,  chilliness  and  disturbed  sleep,  and  on  the  following  morning 
weakness  of  the  legs,  nervous  excitement,  convulsive  movements  of  the  fingers  and 
great  itching  of  the  scalp.  Two  days  later  the  hair  began  to  fall  out  on  the  scalp,  and 
in  a few  days  there  was  general  alopecia.  One  month  later  the  scalp  was  pale,  smooth, 
with  normal  sensibility,  no  itching  and  no  lanugo  hairs.  After  two  years’  treatment 
there  was  no  return  of  growth  of  the  hair. 

Schiitz  (Jos.)  T[  reports  a case  of  alopecia  from  peripheral  lesion.  The  bald  spot, 
however,  was  not  round,  but  triangular  in  shape,  was  not  sharply  limited,  and  there 
was  general  thinning  of  the  hair.  The  bald  spot  corresponded  to  the  area  of  the  occipi 
talis  magnus  nerve. 

Many  cases  could  be  reported  of  somewhat  similar  character,  all  of  which  show  us 
that  alopecia  can  be  the  result  of  a neurosis.  They  have  not  shown,  however,  sufficient 
similarity  in  the  clinical  symptoms  with  alopecia  areata  as  to  justify  us  in  regarding 
the  latter  as  depending  oil  similar  conditions.  Furthermore,  the  shape  of  the  bald 
patch  in  Schiitz’s  case  suggests  a different  cause  from  that  producing  ordinary  alopecia 
areata. 

Nevertheless,  all  these  observations  only  allowed  theoretical  deductions  and  ana- 


* Michelson.  “ Uobcr  Herpes  Tonsurans  und  Area  Celsi.”  Yolkniann’s  Sammlg.,  1S77,  No. 

120;  also  Virch.  Arch.,  Bd.  80  and  99.  f Collier.  Lancet,  London,  1SS1,  r,  p.  951. 

+ Kinney.  Virginia  Med.  Monthly,  1881,  VII,  p.  937. 

§ Unna.  Viertefjahrach.  f.  Dermat.  und  Syph.,  Bd.  xiv,  p.  138. 

||  Fredet.  Archiv.  Central,  1S78. 

Jos.  Schiitz.  “ Beitrag  zur  Aetiologie  und  Symptomatologie  der  Alopecia  Areata.”  Monatsch. 
f.  Prakt.  Dermat.,  1887,  p.  97. 


SECTION  XIV — DERMATOLOGY  AND  S YPHILOGRAPHY. 


251 


logical  conclusions  of  doubtful  justification,  -without  giving  a positive  proof  that  alo- 
pecia areata  depends  upon  some  abnormal  condition  of  the  nervous  system. 

The  experiments  of  Max  Joseph*  are  entitled  to  much  more  consideration,  even  if 
all  will  not  agree  with  him,  that  they  justify  us  in  considering  alopecia  areata  as  a tro- 
phoneurosis, a disease  depending  upon  an  affectiou  of  trophic  nerves. 

He  removed  the  spinal  ganglia  of  the  second  cervical  nerves,  and  observed  between 
the  fifth  and  twenty-seventh  day  following  the  operation,  falling  out  of  the  hairs  in  the 
region  supplied  by  the  injured  nerve.  On  one  or  more  circumscribed,  twenty-pfennig- 
piece-sized  places,  with  normal-looking  skin,  the  hair  became  thinner  in  round,  oval,  or 
longish  areas,  and,  later,  complete  baldness  occurred.  The  spots  also  afterward  increased 
in  size  to  a fifty-pfennig  or  mark  piece.  The  falling  out  of  the  hair  was  not  accompa- 
nied by  any  marked  change  in  the  sensibility  of  the  part.  Microscopical  examination 
showed  atrophy  of  the  hair  papillae,  with  complete  absence  of  hair,  the  root  sheaths 
lying  close  together  or  separated  by  a small  vacant  space.  The  sweat  and  sebaceous 
glands  were  unaffected,  and  there  were  no  symptoms  whatever  of  inflammation  present , 
the  characters  of  the  tissues  being  those  of  the  purest  simple  atrophy.  As  he  was  able 
to  exclude  traumatic  influences  and  vasomotor  nerve  action  as  factors  in  the  production 
of  the  alopecia,  he  believes  that  he  has  proved  the  existence  of  pure  trophic  nerves,  and 
that  alopecia  is  the  result  of  injury  to  them.  In  contradistinction  to  alopecia,  as  has 


Fig.  l. 


been  observed  after  injury  to  the  nervous  system,  in  which  the  form  of  the  spots  has 
been  triangular,  longish,  irregular,  with  thinning  of  the  hair,  the  spots  were  roundish 
and  rather  sharply  limited.  He  endeavors  to  explain  why  the  spots  may  be  round,  and 
also  why  they  present  this  form  as  they  spread  peripherally  and  occupy  new  nerve  ter- 
ritory; but  his  explanation  will  hardly  convince  those  who  have  seen  immense  areas 
deprived  of  hair  by  peripheral  spreading  of  the  disease  from  a small,  round  spot. 

While  it  is  true  that  the  spots  of  alopecia  areata  generally  retain  the  rounded  form 
as  they  continue  to  increase  in  size,  and  have  this  form  even  when  occupying  a large 
area  of  the  skin,  yet  it  not  infrequently  occurs  that  the  disease  ceases  to  spread  at  one 
part  of  the  circle  while  it  extends  by  contiguity  of  tissue  at  other  parts,  in  the  manner 
so  frequently  observed  in  a serpiginous  tubercular  syphilide  or  a lupus  vulgaris  of  the 
extremities.  Thus,  a patch  which  was  previously  round  may  assume  the  form  shown 
in  Fig.  1,  where  the  parts  at  h continue  to  spread,  while  at  a it  is  stationary.  Now,  if 
Joseph’s  explanation  is  correct,  the  extension  at  the  periphery  must  be  equal  at  all 
parts;  that  is,  such  a method  of  spreading  of  a patch  as  I have  described  above  could 
not  occur  as  the  result  of  an  injury  to  the  trophic  nerves. 


* “ Experimentelle  Untersuchungen  iiber  dio  Aetiologie  der  Alopecia  Areata.”  Monat.f . 
Prakt.  Dermal.,  1886,  v.  483. 


252 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


It  is  not  necessary  to  relate  the  objections— evident  to  every  one — to  this  theory,  for 
the  explanation  of  the  occurrence  of  widely  separated  and  irregularly  distributed  sec-  • 
ondary  spots  of  alopecia,  or  of  the  disappearance  of  some  spots  with  the  simultaneous  ■ 
appearance  of  new  ones,  or  of  the  manner  of  spreading  when  general  alopecia  results 
from  gradual  invasion  of  all  parts  of  the  cutaneous  surface,  from  peripheral  spreading, 
bald  spots. 

The  symptoms  in  the  case  reported  by  Wagner,  of  measles  in  a patient  with  alo- 
pecia, in  whom  the  eruption  did  not  appear  upon  the  bald  spots,  as  being  one  supports 
ing  the  neurotic  theory,  can  be  much  easier  explained  by  deficient  blood  supply  in  the 
part,  in  consequence  of  which  the  inflammatory  symptoms  of  measles  could  not  well 
show  themselves. 

Joseph’s  experiments  prove  the  presence  of  trophic  nerves,  and  the  dependence  of  a 
form  of  alopecia  upon  a neurotic  affection.  Whether  this  alopecia  is  similar  to  the 
usual  form  observed  we  will  endeavor,  later  on,  to  consider  and  decide. 

Joseph’s  experiments  have  been  confirmed  by  Mibelli.*  In  the  latter’s  experiments 
the  bald  places  appeared  not  only  after  excision  of  the  spinal  ganglion  of  the  second 
cervical  nerve,  but  also  after  simple  interruption  of  continuity  of  this  ganglion,  and  of 
the  nerve  bundle  passing  from  it.  Also  the  bilateral  and  symmetrical  appearance  of 
spots  far  removed  from  the  region  supplied  by  the  trigeminus  was  observed. 

That  alopecia  is  sometimes  observed  in  persons  with  lowered  nutrition,  that  it  is 
sometimes  hereditary,  or  that  relapses  occur,  as  in  Hardaway’s  case,f  in  which  there 
was  a return  for  four  successive  years  of  alopecia,  always  in  the  Spring,  and  always 
upon  the  same  spot — all  these  facts  have  no  weight  for  or  against  the  parasitic  or 
neurotic  theory. 

Against  the  neurotic  theory  is  the  usual  absence  of  nervous  symptoms,  the  manner  of 
spreading  of  the  patches,  the  results  of  treatment  based  on  this  theory,  and  the  tendency 
of  the  disease  to  spontaneous  recovery  with  restitution  of  the  part  to  a normal  con- 
dition ; for  atrophic  processes  of  neurotic  origin  show  a tendency  to  progressive  loss  of 
tissue. 

While,  therefore,  the  upholders  of  the  parasitic  theory  have  not  definitely  proven 
anything,  although  the  course  of  the  disease  and  the  results  of  treatment  favor  this 
view,  the  defenders  of  the  neurotic  theory  have  shown  that  hair  can  fall  out  from 
injury  to  cutaneous  nerves,  and  that  the  manner  of  falling  out  and  the  shape  of  the 
bald  patches  may  resemble  very  much  that  of  alopecia  areata  as  ordinarily  encountered. 

My  own  observations  on  the  aetiology  and  histology  of  alopecia  areata  comprise  the 
microscopical  examination  of  portions  of  affected  skin  removed  from  the  scalp  of  seven 
different  individuals.  The  duration  of  the  disease  in  these  different  cases  varied  from 
one  week  to  several  years,  and  the  clinical  characters  from  a rapidly  disappearing  to  a 
permanent  alopecia.  These  observations  have  been  carried  on  at  intervals  during  the 
last  eight  years — at  intervals,  because  it  is  difficult  to  obtain  the  consent  of  persons  to 
the  removal  of  a portion  of  skin  from  their  scalp  for  purposes  of  study  only.  Some 
of  the  excised  pieces  were  hardened  in  Miller’s  liquid  and  alcohol,  and  afterward  cut  ■ 
into  sections  and  stained  for  the  anatomical  changes  ; while  others  were  immediately 
put  into  alcohol  and  afterward  cut  and  stained  for  examination  for  organisms  and  ana- 
tomical changes.  The  majority  of  the  pieces  excised  were  removed  from  the  peripheral 
portion  of  a bald  spot  in  process  of  extension,  and  included  a portion  of  skin  from  which 
the  hairs  had  not  yet  all  fallen  out.  In  three  patients,  including  recent  and  old  cases, 
pieces  were  also  removed  from  the  centre  of  a bald  area  in  order  to  study  late  changes. 


* Mibelli  (V).  “ Risorche  sperimentale  sulla  etiologia  dell’  alopecia  areata.”  Boll.  d.  sez.  d. 
cult.  ac.  med.  n.  r.  Accord,  d.  fiaiocrit.  di  Siena,  1887,  v.  636-68. 
f Hardaway.  Journ.  Cutan.  aud  Vener.  Dxaeaaea,  1884,  p.  260. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


253 


In  four  of  the  cases  more  than  one  piece  was  excised,  and  in  one  patient  four  pieces 
were  removed  at  different  periods  of  the  disease. 

I will  first  describe  the  tissue  changes  observed  in  a case  of  about  one  week’s  dura- 
tion, the  size  of  the  patch  being  about  two-fifths  of  an  inch  in  diameter,  round,  sunken 
beneath  the  general  surface  and  devoid  of  hair.  The  excised  portion  included  some  of 
the  hairy  margin.  When  I say  the  spot  was  of  one  week  duration,  that  refers  to  the- 
length  of  time  since  falling  out  of  the  hair  was  observed ; the  cause  of  the  alopecia  must 
have  been  acting  for  a considerably  longer  period  to  produce  the  atrophied  condition  of 
the  hairs  present.  This  patient,  a boy  fourteen  years  of  age,  had  another  spot  of  two 
years’  and  one  of  several  months’  duration.  His  physical  condition  and  general  health 
were  excellent,  and  he  had  never  suffered  from  headache  or  neuralgic  symptoms  in  any 
part  of  the  body.  The  alopecia  disappeared  in  two  spots  in  a few  weeks,  and  in  all 
within  four  months. 

Fig.  2. 


a,  epidermis  ; b,  embryonic  cell  collection  around  bloodvessels;  c,  corium  ; d,  external  root  sheath  of 
hair;  e,  space  previously  occupied  by  hair  shaft. 

After  hardening  in  alcohol  and  sections  made,  the  microscopical  examination  showed 
the  following  anatomical  changes  : The  epidermis,  including  both  the  corneous  layer 

and  rete,  were  normal.  The  papillary  layer  of  the  corium  was  but  very  slightly  changed ; 
in  some  papillie  there  were  signs  of  slight  inflammation,  as  shown  by  the  collection  in 
limited  numbers  of  embryonic  corpuscles  (white  blood  corpuscles?),  while  others 
appeared  to  be  normal.  In  the  corium  proper,  especially  in  its  upper  portion,  beneath 
the  papillary  layer,  signs  of  inflammation  were  very  evident,  especially  in  the  peri- 
vascular regions,  as  shown  by  a marked  embryonic  cell  infiltration  and  dilated  blood 
vessels,  as  shown  in  Fig.  2. 

This  cell  infiltration  was  not  general  throughout  the  corium,  but  limited  to  areas; 
that  is,  there  were  parts  of  the  section  which  appeared  to  be  in  a normal  condition, 
while  others  showed  varying  degrees  of  inflammation.  There  were  no  signs  of  special 
serous  exudation,  the  changes  being  more  like  those  observed  in  a small-celled  infiltra- 


254 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


tion,  such,  for  instance,  as  occurs  in  a chronic  interstitial  nephritis.  Neither  did  the 
inflammation  appear  in  the  perifollicular  region  more  than  in  other  parts,  although  in 
some  sections  a marked  perifolliculitis  was  observed. 

The  Connective  tissue  corpuscles  were  much  more  distinct  than  normal,  and  it 
seemed  that  in  many  places  there  must  have  been  an  active  proliferation  of  them — a 
formative  inflammation. 

The  subcutaneous  tissue  was  normal.  The  blood  vessels  were  dilated  where  the 
embryonic  corpuscle  infiltration  existed  to  any  extent,  and  some  of  the  smaller  arteries 
contained  a fibrinous  coagulum. 

Some  of  the  lymph  vessels  in  the  corium  and  subcutaneous  tissue  were  greatly 
dilated,  and  in  some  situations  contained  a fibrinous  coagulum  similar  to  that  already 
mentioned  as  being  present  in  the  blood  vessels. 

With  the  exception  of  this  coagulum  the  subcutaneous  tissues  were  normal. 

The  sebaceous  and  sweat  glands  were  normal  in  appearance. 

The  hair  follicles  were  either  empty  or  contained  normal  or  languo  hairs.  In  Fig.  2 
is  shown  a hair  follicle  from  which  the  hair  has  fallen  out;  the  external  root  sheath,  as 
far  as  shown,  is  normal  in  appearance  and  the  internal  root  sheath  is  also  to  be  seen. 
Iu  some  cases  no  papilla  was  to  be  found,  the  lower  part  of  the  contents  of  the  follicles 
consisting  of  epithelial  cells  devoid  of  pigment,  these  cells  forming  a small  hair  shaft — 
a lanugo  hair  further  up  in  the  follicle. 

In  other  hairs  and  hair  follicles  nothing  abnormal  was  to  be  detected.  Some  of  the 
hair  shafts  showed  signs  of  interference  with  nutrition,  there  was  splitting  up  and 
fibrillation  of  the  shaft  in  a few  cases  and  an  occasional  stubbed  hair. 

The  anatomical  changes,  then,  in  this  case  were,  a mild  inflammatory  condition  of 
the  corium,  especially  of  the  upper  part,  and  occasionally  of  the  papillary  portion,  a 
small-celled  perivascular  infiltration  and  connective  tissue  corpuscle  proliferation,  a 
falling  out  of  the  hairs  and  their  replacement  by  lanugo  ones,  and  finally  coagulation 
within  some  of  the  blood  vessels  and  lymph  channels.  In  another  case,  in  which  the 
disease  lasted  only  a few  weeks,  the  hair  rapidly  growing  again  after  using  an  oleate  of 
mercury  application,  similar  conditions  were  found. 

The  next  case  from  which  sections  were  studied,  was  that  of  a man  who  in  six 
months’  time  had  lost  fully  one-half  of  the  entire  hair  of  the  scalp.  The  loss  he 
attributed  to  mental  despondency  in  consequence  of  the  death  of  a child  just  previous 
to  the  appearance  of  the  alopecia. 

In  Figs.  3,  4,  5,  6,  7,  8,  9 the  anatomical  changes  are  shown.  There  were  the  same 
signs  of  inflammation  as  in  the  first  case,  only  they  were  more  marked  in  all  parts  of 
the  corium,  including  the  papillary  layer.  The  embryonic  cell  collection  in  perivascular 
areas  was  quite  considerable,  and  beyond  that  region  not  a few  were  also  observed. 

The  inflammatory  changes  are  very  evident  by  examination  of  a part  of  a section 
shown  in  Fig.  3. 

Fibrinous  coagula  within  the  blood  and  lymph  vessels  were  very  distinct,  and  iu  Figs. 
4 and  5 it  is  shown  within  a lymph  vessel  at  the  commencement  of  the  subcutaneous  • 
tissue;  in  Fig.  4 the  extent  and  situation  of  this  coagulum  are  shown  under  a low 
power,  and  in  Fig.  5 a part  of  the  coagulum  is  drawn  under  a higher  power.  As  the 
drawing,  Fig.  4,  was  made  by  means  of  a camera  lucida,  the  proportions  are  correct, 
and  the  lymph  vessel  at  h is  seen  to  be  much  dilated  and  the  coagulum  to  be  a long 
one. 

Some  of  the  arteries  also  contained  a fibrinous  coagulum,  not  only  the  vessels  of  the 
corium  but  also  of  the  subcutaneous  tissue.  This  coagulum  completely  or  only  par- 
tially filled  the  lumen  of  the  vessel. 

In  Fig.  6,  is  shown  a transverse  section  of  such  a vessel. 

The  sweat  glands  were  normal. 


Fig.  3. 


* 

z 


a 


s-e 


"■  Corneou9  'of  vMserw^th^ro^^d^^  infi?^raHon  arixT^d  micrococci.6  ^eePPart 

Fig.  4. 


— * "*“  ‘ sasm  sassr  «w»““ «-■ 

Fig.  5. 


255 


256 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  one  or  two  instances  there  were  signs  of  commencing  degeneration  of  a part  of  a 
sebaceous  gland,  but  beyond  that  they  appeared  to  be  normal. 

The  hairs  had  either  fallen  out  of  their  follicles  or  showed  characters  pointing  to 
such  a process.  The  root  of  the  hair  showed  atrophic  changes  —the  external  root 
sheath  was  becoming  separated  from  the  follicle  sheath  preparatory  to  being  cast  off 
with  the  hair,  or  remained  united,  and  the  hair  without  the  sheaths  falls  out. 

In  Fig.  7,  at  e,  the  separation  between  the  follicle  and  hair-root  sheath  is  shown, 
and  can  be  compared  with  the  normal  condition  present  at  c. 

The  round-cell  collection  is  shown  under  a higher  power,  and  also  its  limitation  to  a 
small  area.  In  this  drawing  two  hair  follicles  are  cut  across — in  the  one  the  external 
root  sheath  is  seen  to  be  separated  from  the  follicle  sheath  while  in  the  other  it  is  con- 
nected with  it,  as  in  normal  conditions. 


Fig.  7. 


Transverse  section  of  a hair  follicle,  a.  sweat  gland  ; 
b.  round-celled  infiltration  ; c.  first,  row  of  cells  of 
external  root  sheaths  united  to  follicle  sheath  ; d. 
section  of  hair;  e.  abnormal  space  between  follicle 
sheath  and  hair-root  sheath. 


Fig.  8. 


Lanugo  hair ; a.  hair 
shaft;  b.  external 
root  sheath. 


None  of  these  three  patients  had  used  any  local  applications  previous  to  removal 
of  the  portions  of  skin,  yet  in  all  the  inflammatory  symptoms  in  the  corium  were 
distinct,  while  the  epidermis  appeared  to  be  normal.  Where  lanugo  hairs  existed 
the  hair  papilla  was  absent  or  only  an  indication  of  its  existence  could  be  detected;  the 
lower  part  of  the  follicle  being  filled  with  epithelial  cells  corresponding  to  those  of  the 
external  root  sheaths  and  the  slight  hair  shaft  commenced  to  be  formed  high  up  in  the 
follicle. 

All  the  lanugo  hairs  which  I have  studied  in  this  disease  had  their  origin  in  this 
manner,  and  probably  continue  to  be  produced  as  long  as  the  external  root  sheath  is 
composed  of  well-formed  epithelial  cells.  If  that  view  is  correct,  then  an  absence,  for 
any  length  of  time,  of  hair  of  any  description  would  indicate  atrophy  or  destruction  ot 
the  hair  follicle  and  consequent  permanent  alopecia. 


SECTION  XTV — DERMATOLOGY  AND  SYPHILOGRAPHY.  257 

In  Fig.  9 is  shown  the  upper  part  of  a hair  follicle  with  a lanugo  hair  and  the 
inflammatory  round-cell  infiltration  in  the  perivascular  tissue  of  the  corium. 

The  external  root  sheath  very  frequently  shows  irregularity  of  contour  from  hyper- 
plasia of  the  epithelium,  the  increase  in  growth  occurring  at  any  part  of  the  follicle, 
although  most  frequent  in  the  lowest  portion. 

Iu  Fig.  10  is  shown  such  a hyperplasia,  and  the  occurrence  of  similar  conditions  in 
this  disease  is  altogether  too  frequent  to  be  regarded  otherwise  than  pathological,  and 
signifies  increased  nutrition  to  the  structures  affected. 

The  next  two  cases,  from  whom  portions  of  skin  were  removed,  had  had  the  disease 
for  years,  and  one  still  has  it;  the  hair  of  the  scalp,  eyebrows  and  heard  of  the  latter  has 
all  fallen  out,  and  iu  the  former  the  hair  grew  in  after  several  months’  treatment,  in  all 
the  situations  affected,  except  the  lower  part  of  the  occiput,  and  here  not  even  lanugo  hairs 


Fig.  9. 


Fig.  10. 


Fig.  11. 


Transverse  sec- 
tion of  artery 
showing 
thickened 
walls,  a.  lu- 
men of  vessel. 


were  to  he  observed  when  he  first  came  under  my  observation  seven  or  eight  years  ago, 
and  none  have  appeared  since,  consequently  the  spot  will  be  permanently  bald.  Ia 
removing  pieces  of  the  skin  I always  took  some  from  the  spreading  periphery.  In  these- 
two  patients  the  same  inflammatory  changes  already  described  were  observed,  hut  im 
addition  there  was  thickening  of  the  walls  of  many  of  the  blood  vessels,  as  shown  in 
Fig.  11,  and  atrophy  of  others. 

In  some  vessels  the  lumen  seemed  almost  closed,  while  the  walls  were  several  times 
thicker  than  normal.  In  both  cases  there  was  thinning  of  the  epidermis  and  diminu- 
tion in  the  size  of  the  epidermic  cells.  In  the  case  of  subsequent  recovery  the  sebaceous 
glands  were  particularly  well  developed,  as  a rule  ; in  the  other  patient  more  or  less 
degeneration  was  frequently  observed  in  some  glands,  while  others  were  unaffected. 

The  hair  follicles  were  either  devoid  of  hair  or  contained  a lanugo  hair,  or  a hair  in 
process  of  being  cast  off.  In  this  case  the  hair  showed  the  nutrition  changes  already 

described  by  observers,  and  which  do  not  differ  much  from  those  seen  in  normally  fall- 
Vol.  IV— 17 


258 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ing  out  hairs.  These  changes  will  he  fully  described  in  a more  complete  paper  on  this 
subject,  and  they  are  not  necessary  for  the  purpose  of  the  present  discussion. 

The  fat  tissue  was  normal  in  both  cases,  as  also  the  subcutaneous  tissue,  which  was 
present  in  normal  amount,  the  fat  cells  being  well  developed. 


Fig.  13. 


Lower  part  of  hair  follicle  in  case 
of  chronic  alopecia  areata,  a. 
hair  papilla:  b.  empty  space 
between  papilla  and  follicle 
epithelium ; c.  space,  probably 
artificial,  from  hardening  in 
M tiller  liquid  ; d.  pigment  col- 
lection. 

The  appearances  I am  now  about  to  describe  were  observed  in  a case  that  I saw  only 
once,  about  eight  years  ago.  The  disease  at  that  time  had  existed  several  years  and 
occupied  almost  the  eutire  scalp,  and  I have  lately  learned  that  it  still  continues  in  as 
severe  a ibrm  as  at  that  time.  Sectious  of  the  skin  removed  showed  more  or  less  atrophy 
of  all  the  structures  except  the  blood  vessel  walls.  The  epidermis  was  thinner,  tlie 
corium  also  somewhat  thinner ; there  was  considerable  atrophy  of  the  fat  tissue,  the 
sebaceous  glands  in  some  cases  were  normal,  but  in  many  instauces  were  degenerating 
and  disappearing.  Sometimes  only  the  remains  of  the  glands  were  to  be  observed.  In 
Fig.  12  is  represented  a part  of  a sebaceous  gland,  the  structure  of  which  is  already 
broken  down  in  the  greater  part  and  the  rest  undergoing  degeneration. 


SECTION  XIV DERMATOLOGY  AND  SYPHILOGRAPHY. 


259 


The  fat  tissue  showed  the  ordinary  appearances  observed  in  simple  atrophy,  but,  as 
in  the  case  of  the  sebaceous  glands,  there  was  considerable  fat  tissue  but  slightly,  if 
any,  affected. 

The  hair  follicles  showed  signs  observed  in  normal  falling  of  hair,  or  marked  signs 
of  atrophy  and  disappearance  of  papilla  and  follicle. 

Depending  upon  the  extent  of  these  changes  lanugo  hairs  were  present,  or  only  an 
empty  space  within  the  hair  follicle  previously  occupied  by  a hair.  The  anomalous  dis- 
tribution of  pigment  was  very  striking  in  several  instances.  Instead  of  being  in  the 
usual  situation,  it  was  distributed  in  clusters  irregularly  within  the  hair  papilla,  among 
the  epithelial  cells  of  the  hair  follicle  and  in  the  perifollicular  connective  tissue.  In 
Fig.  12  this  anomalous  pigment  deposition  is  shown. 

Iu  Fig.  13,  however,  very  different  anatomical  changes  are  seen.  The  follicle 
sheaths  are  atrophied  and  shrunken,  the  basement  membrane  is  greatly  thickened,  show- 

Fig.  14. 


Section  of  hair  follicle  in  advanced  permanent  alopecia  areata,  a.  root  of  hair  ; b.  basement  membrane; 

c.  follicle  sheaths. 

ing  the  teeth-like  striae,  the  hair  papilla  has  disappeared,  and  the  hair  itself  is  being 
cast  out. 

Here  it  is  seen  that  the  process  does  not  resemble  the  normal  one,  for  there  are  no 
structures  left  behind  from  which  a new  hair  could  arise.  Fig.  13  represents,  no  doubt, 
an  earlier  stage  of  a similar  process.  Iu  it  the  entire  follicle  has  lost  its  usual  form,  the 
papilla  is  still  normal  as  regards  shape,  and  pigment  is  deposited  in  it  in  irregular 
masses.  The'  condition  shows  interference  with  hair  growth  from  disturbance  iu  the 
circulation  apparatus. 

This  patient  was  sent  to  me  for  consultation,  and  from  the  above  changes  in  struc- 
ture, I gave  the  opinion  that  the  alopecia  would  be  permanent. 

The  hairs  were  either  absent  from  the  atrophied  hair  follicles,  or,  if  present,  were  of 
the  lanugo  variety  almost  without  exception.  In  the  rare  example  of  papilla  hairs  the 
shaft  showed  longitudinal  splitting  up,  fibrillation  and  easy  transverse  fracture. 


260 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  Fig.  15  is  shown  the  degeneration  of  a sebaceous  gland  and  fibrillation  of  a hair. 
The  base  of  the  follicle  is  filled  with  round  cells  and  the  follicle  sheaths  are  indistinct. 
The  section  did  not  color  well,  and  the  transverse  fracture  observed  in  the  shaft  is,  no 
doubt,  mostly  artificial,  consequent  on  the  hardening  of  the  section,  the  normal  coher- 
ence of  the  cells  with  each  other  having  become  much  interfered  with,  from  atrophy. 

The  blood  vessels  in  some  places  were  atrophied  while  the  arteries  showed  thickened 
walls,  from  increase  in  the  connective  tissue,  with  diminution  in  the  size  of  the  lumen 
of  the  vessel,  a condition  similar  to  that  shown  in  Fig.  11. 

Such  were  the  anatomical  characters  observed  in  these  different  cases  of  alopecia 
areata;  in  all  of  them  inflammatory  changes  were  present,  a round-celled  infiltration  of 
limited  extent,  confined,  in  great  part,  to  the  perivascular  regions,  with  increase  in  the 


a.  sebaceous  gland  ; b.  broken-down  external  root  sheath;  c.  hair  shaft;  d.  root  of  hair;  e.  follicle  sheaths. 

connective-tissue  corpuscles  of  the  parts.  This  inflammation  was  not  specially  peri- 
follicular, only  as  the  glandular  structures  have  a richer  supply  of  blood  vessels  than  the 
eorium  tissue,  the  inflammation  was  often  well-marked  around  these  structures;  there 
was  also  coagulation  of  lymph  in  a number  of  lymph  vessels  in  the  more  recent  cases, 
with  consequent  stoppage  of  the  current  in  that  part;  there  was,  further,  coagulated 
fibrine  in  some  of  the  arteries,  large  and  small,  and,  finally,  a thickening  of  the  blood 
vessel  walls  in  the  more  advanced  cases.  As  regards  the  glandular  structures,  only  the 
hair  follicles  were  affected  in  recent  cases;  in  more  advanced  ones  the  sebaceous  glands 
also,  and  in  the  worst  case  there  was  a partial,  but  only  a partial,  atrophy  of  the  sub- 
cutaneous fat  tissue.  The  seat  of  the  inflammatory  changes  pointed  to  the  causative 
agent  as  one  not  acting  specially  upon  the  hair  follicles,  but  in  a more  general  manner 


Fig.  15. 

'4- 


d 


SECTION  XIV DERMATOLOGY  AND  SYPTIILOGRAPHY 


201 


•throughout  the  coriurn;  and  the  coagulation  within  the  lymph  and  blood  vessels 
denoted  that  the  agent  had  not  a central  but  a local  seat. 

The  changes  observed  in  the  recent  cases  show  that  the  depression  of  the  patches 
observed  in  this  disease  depends  at  its  commencement  upon  the  absence  of  the  hair,  as 
already  suggested  by  Hutchinson,  and  not  upon  a primary  disappearance  of  the  subcu- 
taneous fat  tissue  and  atrophy  of  the  cutis,  as  maintained  by  Michelson. 

From  these  observations,  that  question  is  no  longer  one  of  doubt;  the  sections  show 
anything  hut  au  atrophy  of  the  connective  or  fat  tissues  in  the  early  stages  of  the 
disease.  Afterward,  in  the  very  severe  cases,  the  secondary  disappearance  of  the  seba- 
ceous glands  and  hair  follicles  are  additional  factors  in  the  production  of  the  depression 
of  the  skin.  This  disappearance  of  the  glands  and  apparatus,  however,  as  we  have 
seen,  occurs  only  rarely,  and  probably  never  occurs  in  these  cases  of  temporary  alo- 
pecia. When  it  does  occur,  as  is  shown  by  the  absence  for  a length  of  time  of  even 
lanugo  hairs,  there  is  no  possibility  of  the  hair  growing  again.  These  changes  in  the 
glandular  apparatus  depend  evidently  upon  an  atrophy,  the  result  of  interference  with 
their  proper  nutrition  from  inflammatory  changes  and  thickening  of  the  blood  vessel 
walls  and  consequent  narrowing  of  their  lumen.  A temporary  narrowing  is  observed 
in  all  cases,  and  in  the  worst  case  observed  by  me,  new  connective  tissue  was  present 
in  considerable  amount,  and  the  muscular  layer  also  appeared  to  be  thicker  than 
normal.  The  interference  to  the  growth  of  the  hair  would  seem  to  depend,  partly  at 
least,  upon  the  thickened  blood  vessel  walls,  and  in  the  recent  cases,  also  upon  the  pre- 
sence of  coagula  in  the  arteries  and  lymph  vessels,  interfering  with  the  nutrition  supply. 
If  an  artery  should  be  closed,  the  hair  could  fall  out  very  suddenly  in  an  area  of  con- 
siderable size,  namely,  the  area  supplied  by  that  vessel;  or  a considerable  extent  of 
lymph  vessels  could  be  clogged,  as  shown  in  Fig.  4,  and  the  same  result  could  follow. 

Thus,  I would  explain  the  falling  out  of  the  hairs  suddenly  at  the  commencement 
of  the  disease,  and  why  sometimes  a larger  area  is  affected  than  at  other  times.  The 
paleness  of  the  skin  and  absence  of  all  inflammatory  symptoms  depends  upon  the 
deficient  blood  supply  to  the  part  and  the  fact  that  the  inflammatory  changes  occur 
principally  in  the  sub-papillary  layer,  and  that  the  process  is  a small-celled  infiltration. 
Perhaps,  from  a clinical  standpoint,  it  could  be  questioned  that  there  is  an  inflamma- 
tion present;  the  section,  however,  from  even  the  most  recent  case,  cannot  leave  any 
doubt  upon  the  subject,  for  the  inflammatory  changes  are  easily  recognized.  In  the 
most  advanced  and  severest  case  studied  there  was  some  atrophy  of  the  subcutaneous 
fat  tissue,  so  that  this  can  aid  in  making  the  depression  of  the  affected  part,  but  as 
already  mentioned,  it  does  not  occur  in  recent  cases. 

The  process,  then,  is  an  inflammatory  one;  a small-celled  infiltration  leading  to  per- 
manent or  temporary  nutrition  changes;  to  permanent  or  temporary  alopecia;  an  inflam- 
matory affection  of  the  corium,  and  not  a disease  primarily  of  the  hair  structures. 

In  Joseph’s  experiments,  it  will  be  remembered  that  he  produced  a falling  out  of  the 
hair,  the  result  of  a pure  atrophy  of  the  hair  structures,  and  that  there  were  no  signs 
whatever  of  an  inflammatory  character  in  the  sections  studied  by  him.  If  these  micro- 
scopical examinations  of  sections  were  correct,  and  we  have  no  reason  to  doubt  their 
correctness,  then  the  process  in  the  six  patients  studied  by  me  were  not  examples  of  the 
disease  produced  experimentally  by  him,  that  is,  the  disease  was  not  a trophoneurosis. 

That  being  admitted,  we  must  seek  for  some  other  cause  than  a trophoneurotic  one. 
As  a vasomotor  disturbance  of  central  origin,  I think  no  one  would  consider  it  for  a 
moment,  so  we  must  look  for  a local  cause. 

As  regards  its  dependence  upon  organisms,  I have  studied  sections  after  staining 
them  in  the  manner  recommended  by  Yon  Selilen,  as  well  as  after  the  usual  methods 
for  their  detection,  and  will  briefly  give  the  results  of  my  observations.  On  the  surface 
of  the  skin,  around  hairs  and  sometimes  around  the  shaft,  I found  organisms  resembling 


262 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


the  tinea  trichophytina  and  tinea  versicolor  fungus  occasionally.  In  one  case  I saw 
organisms  apparently  like  those  described  by  Von  Sehlen. 

Staining  sections  from  the  most  recent  case,  that  of  a week’s  duration,  by  Gram’s 
method  and  by  the  different  aniline  dyes,  decolorizing  with  alcohol,  and  examining  with 
the  microscope,  showed  in  the  lymph  spaces  of  the  corium  and  in  the  walls  of  some  of 
the  small  blood  vessels  small  round  bodies  arranged  in  groups  and  deeply  stained.  They 
were  about  the  same  size,  were  arranged  in  groups  and  zooglea  masses,  and  were  unaf- 
fected by  acetic  acid  or  alkalies.  The  majority  were  to  be  found  in  the  lymph  spaces 
of  the  middle  part  of  the  corium;  a few  were  present  in  some  of  the  papilla,  and  occa- 
sionally they  were  found  deep  down  in  the  corium.  They  were  shown  to  be  micrococci 
by  the  staining  and  the  action  of  the  acids  and  alkalies.  They  were  present  in  tissue 
which  often  showed  no  signs  of  inflammation  in  the  area  of  their  location,  and  fre- 
quently one  could  trace  a long  row  of  these  organisms  from  the  zooglea  mass  into  the 
surrounding  tissue,  along  the  course  of  the  lymph  capillaries.  When  these  rows  of 


Fig.  16. 


Section  showing  organisms  in  lymph  vessels  and  walls  and  lumen  of  blood  vessels,  a.  corneous  layer; 

6.  rete;  c.  corium;  d.  blood  vessel;  e.  micrococci. 

organisms  were  studied  by  high  powers  it  could  be  seen  that  diplococci  are  quite 
frequent.  In  a case  of  several  months’  duration,  similar  organisms  were  found  in  simi- 
lar situations  but  were  more  numerous. 

In  Fig.  16  their  situation  in  the  lymph  vessels  and  blood  vessels  is  shown.  As  the 
specimens  were  decolorized  with  alcohol,  the  inflammatory  round-cell  infiltration  is  not 
seen,  but  it  was  slight. 

The  organisms  were  present  in  larger  numbers,  both  in  inflamed  aud  normal  tissue, 
and  were  especially  to  be  observed  in  the  corium,  occupying  the  lymph  spaces  and 
extending  by  traveling  through  these  channels.  In  Fig.  17  is  shown  large  masses  in 
these  lymph  channels,  the  immediately  surrounding  connective  tissue  appearing  normal. 

In  Fig.  18  organisms  from  the  same  patient  as  those  of  Fig.  17  are  shown,  under  a 
higher  power.  The  number  of  the  organisms  aud  their  grouping  are  marked.  Their 
presence  around  blood  vessels  is  also  shown  in  Fig.  3 and  Fig.  16. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


2G3 


In  the  two  cases  of  several  years’  duration  they  were  also  found,  but  in  much  less 
number.  In  the  most  severe  case  of  all  I did  not  examine  for  them,  as  the  specimen 
had  been  hardened  in  Muller’s  liquid,  and,  consequently,  was  unfit  for  such  studies. 
The  specimens  of  the  other  ones  had  been  hardened  with  alcohol  alone. 

I have  already  given  you  the  histological  characters  of  the  skin,  and  endeavored  to 
explain  the  cause  of  the  falling  out  of  the  hair,  the  depression  in  the  skin  at  the  affected 
part,  etc.  Now,  I wish  to  inquire  if  these  organisms  are  accidental,  or  essential  to  the 
anatomical  changes  described.  You  will  note  the  large  number  present  in  the  tissues, 


Fig.  17. 


Micrococci  in  the  lymph  vessels,  a.  micrococci;  6.  connective  tissue  of  corium. 


the  almost,  if  not  entirely,  normal  condition  of  the  skin  in  many  places,  and  the 
inflammatory  changes  in  other  parts — a condition  suggestive  of  a local  agent  acting  in 
different  places.  Organisms  in  such  quantity,  and  with  such  anatomical  characters  of 
the  habitation,  do  not,  I believe,  occur  in  any  other  condition,  as  far  as  known  at 
present. 

Their  number  and  situation  explain,  without  argument,  the  condition  of  the  lymph 
vessels,  and  also  of  the  blood  vessels.  It  is  true  that  micrococci  are  present  in  other 
pathological  conditions,  but  then  the  tissues  show  marked  changes  in  nutrition  in  such 


Fig.  18. 


Micrococci  in  lymph  vessels,  a.  micrococci. 


cases,  while  in  alopecia  the  changes  are  slight  at  first,  or  perhaps  not  appreciable, 
although  organisms  are  present. 

The  manner  of  spreading  of  the  disease  is  furthermore  easily  comprehended  when 
we  consider  how  these  organisms  travel  in  the  lymph  vessels,  just  as  in  erysipelas,  and 
in  no  other  way,  do  I think,  can  we  explain  satisfactorily  the  manner  in  which  the  bald 
patches  spread. 

The  deep  seat  of  the  organisms  also  explains  why  contagion  occurs  so  rarely,  if  ever 
it  occurs,  and  the  absence  of  marked  contagious  power  is  no  longer  an  argument  against 
the  parasitic  nature  of  the  disease. 


264 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Finally,  the  frequent  failure  of  anti-parasiticides  in  the  treatment  of  the  disease  is 
easily  understood;  for  the  organisms  are  too  deeply  seated  to  he  destroyed  with  ordi- 
nary anti-parasitic  remedies.  To  insure  success  a remedy  must  be  chosen  that  will 
penetrate  deeply  from  without,  or  the  organisms  must  be  destroyed  by  internally  acting 
agents,  as  white  blood  corpuscles,  or  the  ground  must  be  made  unfavorable  for  their 
growth  and  multiplication. 

Treatment. — As  alopecia  areata  is  a disease  which  generally  tends  to  disappear  spon- 
taneously and  at  no  definite  period  of  existence,  sometimes  after  having  existed  only  a 
few  weeks,  and,  again,  only  after  many  months,  or  even  years,  it  is  very  difficult  to 
judge  of  the  positive  results  of  any  special  method  of  treatment,  even  when  a consider- 
able number  of  cases  have  been  under  observation,  and  it  is  absolutely  impossible  if 
only  two  or  three  have  been  treated. 

I have  treated  about  thirty  cases  during  the  last  eight  years,  and,  in  a number  of 
these  cases,  have  experimented  with  different  remedies  upon  the  same  person,  either 
upon  a single  patch  at  different  times,  or,  when  the  patient  had  more  than  one  bald 
spot,  upon  the  different  ones  at  the  same  time,  using  different  substances  on  different 
places,  with  the  object  of  observing  their  comparative  value.  I have  used  electricity, 
stimulating  or  irritating  applications,  as  capsicum,  eantharides,  etc.,  different  mercurial 
preparations,  chrysarobin  and  croton  oil.  The  sulphur  preparations  were  not  made  use 
of,  as  the  observations  of  Dr.  Thin  on  fifteen  cases  made  any  experiment  on  my  part 
unnecessary  for  the  present  study. 

Unna  reports  a case  cured  by  electricity,  that  had  resisted  all  the  usual  methods  of 
treatment,  but  this  must  have  been  a case  of  long  standing,  and  the  result  due  to  the 
effect  of  the  agent  producing  the  changes,  for  I have  never  seen  any  benefit  whatever 
from  its  use,  in  any  form,  upon  recent  cases  of  the  disease.  That  it  can  be  of  benefit  in 
restoring  the  part  to  a normal  condition  after  the  active  (progressive)  stage  is  passed,  is 
not  difficult  to  understand,  and  it  could  or  should  be  used  in  chronic  cases.  Stimu- 
lating or  mildly  irritating  (inflammation-producing)  preparations,  as  capsicum,  ammonia, 
eantharides,  etc. , I have  not  found  to  be  of  any  value,  if  their  action  is  limited  to  the  pro- 
duction of  hypersemia  or  slight  superficial  catarrhal  condition  of  the  skin  ; but  if  their 
application  be  prolonged  or  sufficiently  often  repeated  to  produce  a deeper  dermatitis, 
and  this  inflammation  be  kept  in  existence  for  a length  of  time,  and  in  a somewhat 
intense  form,  in  order  that  emigration  of  corpuscles  be  greater  than  takes  place  in  a 
simple  serous  inflammation,  then  I think  we  are  generally,  if  not  always,  able  to  con- 
trol the  spreading  of  the  disease.  The  explanation  I have  for  this  result  will  appear 
directly.  Of  the  mercurial  preparations,  I have  used  the  oleate  in  two,  four,  six  and 
ten  per  cent,  solutions,  and  while  some  cases  have  been  cured  rapidly  by  this  remedy, 
others  have  not  been  benefited.  A four  or  six  per  cent,  solution  is  strong  enough, 
unless  the  object  be  to  inflame  the  skin,  and  this  can  be  better  accomplished  by  other 
means.  The  cases  which  have  been  most  benefited  have  been  recent  ones,  but  the 
remedy  is  an  unreliable  one,  not  only  in  this  disease,  but  in  those  which  all  admit  to  he 
parasitic,  as  ringworm,  for  instance  ; consequently  the  failure  to  cure  every  case  of 
alopecia  areata  with  it  is  no  argument  against  the  parasitic  nature  of  the  disease,  while 
its  prompt  cure  of  some  cases  of  recent  origin  favors  the  parasitic  theory.  White  pre- 
cipitate ointment  has  never  seemed  to  me  to  be  of  any  value,  although  I have  made 
frequent  use  of  it.  The  same  unfavorable  results  were  observed  when  the  mercurial 
preparation  was  mixed  with  lanolin  or  agnine.  The  bichloride  of  mercury  was  of  value 
in  some  cases,  and  in  others  no  beneficial  effect  was  observed.  As  I did  not  follow  the 
method  for  its  application  recommended  by  Lassar,  that  is,  perhaps,  the  reason  for  the 
difference  in  the  results  obtained  by  us.  My  own  observations  from  the  use  of  the 
mercurial  preparations,  especially  of  the  bichloride,  lead  me  to  the  conviction  that  any 
organisms  existing  on  the  surface  of  the  skin  are  not  the  cause  of  the  disease. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGllAPHY. 


265 


Chrysarobin  of  the  strength  of  15  to  20  grains  to  an  ounce  of  lanolin  has  given  me 
the  best  results  among  the  remedies  properly  called  directly  anti-parasitic.  It  will  not 
cure  every  case  ; but  I have  often  seen  spots  rapidly  cured  and  the  spreading  process 
stopped,  by  the  use  of  this  remedy.  As  an  example  of  its  comparative  value,  I treated 
a boy  last  year  who  had  several  large  areas  of  alopecia  areata  of  over  one  year’s  duration, 
with  either  oleate  of  mercury,  bichloride  of  mercury,  white  precipitate  ointment  or 
chrysarobin  applied  to  the  spots,  the  chrysarobin  being  applied  to  the  largest  of  the 
bald  areas.  Within  two  weeks’  time  an  increase  in  the  growth  of  the  hair  in  the  area 
treated  by  the  chrysarobin  was  observed,  with  subsequent  rapid  return  to  a normal 
condition,  while  the  other  places  remained  unchanged. 

The  results  obtained  by  the  mercurial  preparations  and  chrysarobin,  point  to  the 
disease  being  parasitic  in  its  origin,  for  surely  these  remedies  can  have  no  beneficial 
effect  in  neurotic  conditions,  unless  their  action  be  traced  to  a stimulating  effect,  a view 
hardly  correct,  at  least  as  regards  chrysarobin.  If  to  these  results  we  add  those  obtained 
by  Dr.  Thin  with  sulphur  ointment,  and  by  Lassar  with  corrosive  sublimate,  I do  not 
see  how  any  one  can  doubt  the  parasitic  origin,  unless  they  doubt  the  results  obtained, 
or  at  least  described.  The  failure  of  the  anti-parasitic  remedies  in  some  cases,  can  be 
best  explained  by  the  view  of  the  deep  seat  of  the  organisms,  as  I have  already 
pointed  out,  comparing  the  results  with  those  obtained  in  lupus  vulgaris  when  treated 
by  anti-parasitic  agents. 

Croton  oil  has  given  the  best  results  in  the  treatment  of  this  disease,  when  used  in 
the  proper  strength  to  accomplish  the  object  in  view  viz  : the  production  of  a dermatitis 
in  which  the  exudation  or  rather  infiltration  will  contain  a considerable  number  of 
white  blood  corpuscles.  If  pure  croton  oil  is  used  a very  intense  inflammation  of  a 
suppurative  character  is  almost  certain  to  be  produced  around  the  hair  follicles,  a 
suppurative  perifolliculitis  by  which  there  is  danger  of  destruction  of  the  hair  follicle. 
A fifty  per  cent,  preparation,  the  croton  oil  being  mixed  with  olive  oil  or  some  other 
suitable  substance,  should  be  used  at  first,  and  this  made  stronger  or  weaker  afterward, 
according  to  the  vulnerability  of  the  tissue,  that  is,  according  to  the  intensity  of  the 
inflammation  produced.  As  intensity  of  inflammation  in  any  case  depends  upon 
the  vulnerability  of  the  tissue  being  acted  upon,  upon  tbe  agent  acting,  and  the 
duration  of  action  of  the  agent,  so  we  can  with  a weak  preparation  of  the  croton  oil 
accomplish,  by  frequent  application  or  long  duration  of  action,  without  danger,  the 
same  results  as  by  a stronger  preparation.  An  inflammation  of  the  character  I have 
described  should  be  produced  and  maintained  for  perhaps  a few  weeks,  and  the  result 
studied,  observing  whether  the  disease  is  spreading  or  the  alopecia  disappearing.  The 
application  should  be  made  not  only  to  the  bald  area  but  also  to  the  hairy  margin. 
With  this  agent  I have  often  seen  the  disease  stop  spreading  in  the  region  treated 
while  it  spread  at  other  parts.  If  it  was  a neurosis  surely  such  an  effect  would  not  be 
produced,  nay,  I would  say  could  not  be  produced.  The  result  is  the  same  as  can  be 
obtained  in  treating  a portion  of  a serpiginous  syphilide  by  a mercurial  ointment  ; the 
part  treated  becomes  free  of  the  disease  while  the  remainder  of  the  lesion  continues  to 
spread;  and  syphilis  is  an  infectious  disease,  with  organisms,  no  doubt,  in  the  corium, 
even  if  they  have  not  been  cultivated  or  successfully  inoculated  in  the  lower  animals. 

The  beneficial  results  of  the  croton  oil  depend,  I believe,  upon  the  inflammation 
produced;  the  white  blood  corpuscles  passing  out  of  the  vessels  into  the  lymph  channels, 
the  situation  of  the  microccoci  already  described,  act  as  anti-parasiticides,  and  destroying 
the  organisms  remove  the  agent  producing  the  disease.  As  this  emigration  of  corpus- 
cles occurs  especially  in  chronic  inflammations  of  some  intensity,  the  necessity  of  main- 
taining for  some  time  the  dermatitis  produced  by  the  action  of  the  croton  oil  is  apparent. 

Any  agent,  of  course  which  will  produce  such  a dermatitis,  will  act  as  well  as  croton 


266 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


oil;  the  reason  I recommend  this  substance  is  because  as  yet  it  has  given  me  the  best 
results.* 

From  what  we  have  already  learned  of  the  histological  characters  of  alopecia,  it  is 
evident  that  there  are  some  cases  in  which  treatment  cannot  be  of  any  service  what- 
ever. When  the  hair  follicles  are  destroyed  the  alopecia  must  he  permanent,  and  there 
are  some  cases  where  lanugo  hairs  are  still  being  produced,  but  the  blood  vessel  walls 
are  too  much  changed  to  admit  of  restoration  to  a normal  condition.  If,  however,  we 
treat  recent  cases  in  the  manner  I have  described,  regarding  the  disease  as  parasitic  and 
the  location  of  the  organisms  as  seated  in  the  corium,  I believe  the  results  will  be 
entirely  different  from  the  treatment  based  on  the  neurotic  theory. 

As  the  nature  of  the  ground  is  an  important  factor,  perhaps  the  most  important,  in 
most  parasitic  diseases,  it  follows  that  everything  should  he  done  that  is  necessary  to  bring 
the  general  system  into  a normal  physiological  condition.  It  is  not  necessary  to  enter 
into  a discussion  of  this  subject,  for  each  case  must  be  treated  according  to  the  special 
condition  present.  A cure  of  the  alopecia  by  internal  medication  which  corrects  the 
nutrition  of  the  tissues,  is  no  proof  that  the  disease  is  not  parasitic,  for  the  changes 
produced  in  the  skin  about  the  period  of  puberty,  for  instance,  will  usually  cause  a 
ringworm  to  disappear  without  local  treatment. 

As  an  additional  argument  for  the  parasitic  theory  I might  mention  the  tendency  to 
invasion  of  certain  tissues,  viz.,  those  parts  specially  provided  with  well  developed  hair, 
as  scalp,  beard,  axilla,  etc.,  the  capillary  production  being  the  result  not  of  the  nervous 
system  but  of  hereditary  influences.  The  selection  of  certain  tissues  by  certain  organ- 
isms is  a well  established  fact,  and  should  be  considered  in  a discussion  of  the  aetiology 
of  alopecia.  If  the  disease  were  a neurosis  this  selection  of  certain  areas  covered  with 
hair  would  not  occur. 

The  results  of  my  observations  would  tend  to  show,  then,  that  alopecia  areata  is  a 
parasitic  disease;  that  the  organisms  are  microccoci  and  have  their  seat  specially  in  the 
lymph  vessels;  that  they  give  rise  to  inflammatory  changes  in  the  corium,  and  frequent 
coagulation  of  fibrine  in  the  lymph  and  blood  vessels;  that  the  depression  of  bald  areas, 
in  recent  cases,  depends  upon  the  loss  of  hair  and  diminished  blood  supply  in  the  part, 
and  in  old  cases,  in  addition  to  these  changes,  the  destruction  of  the  sebaceous  glands 
and  an  atrophy  of  the  corium  and  epidermis;  aud  finally  that  in  anti-parasitic  remedies, 
in  the  widest  sense  of  that  term,  we  have  the  only  means  which  have  any  effect  upon 
recent  cases  of  the  disease. 

I have  further  endeavored  to  show,  by  the  clinical  symptoms,  the  histological 
changes  and  the  effects  of  certain  local  agents  to  the  parts,  that  ordinary  alopecia  areata 
cannot  depend  upon  a disturbance  of  the  nervous  system  for  its  cause. 

DISCUSSION. 

In  the  discussion,  Dr.  Unna  said  that  just  as  summer  changes  to  winter  and 
back  again,  so  do  the  views  upon  the  aetiology  of  alopecia  first  favor  the  neurotic  then 
the  parasitic  theory. 

He  himself  might  be  said  to  hold  both  views.  One  must,  however,  have  his  mind 
directed  to  the  possibility  of  a parasitic  origin  when  one  sees,  as  he  has,  a father  and 
daughters  in  one  family  simultaneously  affected.  On  the  other  hand,  an  alopecia 
following  an  injury  to  the  scalp,  as  from  a needle  broken  off  in  the  tissues,  rather 
favors  the  opposite  view,  and  one  must  recognize  a neurotic  origin  for  cases  of  general 
alopecia  following  shock,  etc.  He  could  only  offer  his  congratulations  to  Dr.  Robin- 
son on  the  scrupulous  original  work  which  he  had  done,  and  the  admirable  manner 
in  which  he  had  presented  the  result  of  his  investigations.  The  two  theories  rise 


*■  Since  reading  this  paper  I have  used  Chrysarobin  in  several  cases,  with  excellent  results. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


2G7 


side  by  side,  each  having  points  of  strength  and  weakness.  He  thought  it  would  be 
a long  time  before  either  became  the  recognized  one  for  all  cases  of  alopecia  areata. 
To  prove  the  parasitic  theory,  isolation,  cultivation,  and  transmission  were  neces- 
sary. 

Dr.  Thin,  after  a careful  examination  of  Dr.  Robinson’s  specimens,  satisfied 
himself  as  to  the  undoubted  presence  of  cocci,  as  described  by  Dr.  Robinson,  in  the 
lymphatic  vessels  and  in  the  arteries,  and  of  the  presence  of  fibrinous  coagula  in  the 
vessels.  He  considered  that  these  cocci  were  identical  in  form  and  size  with  the 
cocci  described  by  himself  some  years  ago  as  being  present  in  the  hairs  in  alopecia 
areata,  and  named  by  him  bacterium  decalvans. 

Dr.  Thin  had,  by  repeated  investigations,  after  the  publication  of  Yon  Sehlen’s 
paper,  confirmed  his  previous  views  as  to  the  presence  of  these  cocci  in  the  interior 
of  the  hairs,  but  the  demonstration  was  by  no  means  easy.  The  same  aniline  dyes 
that  are  used  in  staining  cocci  also  stain  the  hair  substance  proper.  In  the  various 
manipulations  that  are  necessary  to  differentiate  the  hair  and  the  cocci,  as  recom- 
mended by  Von  Sehlen,  the  cocci  that  are  lying  free  on  the  split  surfaces  are  very 
apt  to  be  washed  away.  The  more  manipulation  the  hair  undergoes  in  staiuing  the 
less  chance  of  the  cocci  being  left.  Still,  if  these  manipulations  are  carefully  per- 
formed, cocci  can  be  found  lying  on  the  surface  of  the  fibres  which  are  formed  by 
the  splitting  of  the  hair. 

As  regards  the  pathogenic  value  of  this  bacterium,  Dr.  Thin  considered  himself 
entitled  to  criticise  with  severity  some  of  the  German  writers,  particularly  Dr.  Michel- 
son,  the  author  of  the  chapter  on  Alopecia  areata  in  Von  Ziemssen’s  “Handbook.” 
He  considered  it  somewhat  remarkable  that  the  editors  of  the  book  allowed  an  obser- 
vation of  Dr.  Michelson’s  to  appear  in  which  that  gentleman  expresses  his  belief  that 
the  objects  described  by  Dr.  Thin,  and  figured  by  him  in  a paper  accepted  for  publi- 
cation in  the  Royal  Society,  were  only  air  bubbles. 

As  regards  the  value  of  Dr.  Michelson’s  opinion  Dr.  Thin  is  ignorant,  but  in 
regard  to  the  German  criticisms  on  recent  researches  on  alopecia  areata,  he  would 
remark  that  the  same  gentleman,  who,  when  his  paper  appeared,  could  not  accept 
the  fact  that  bacteria  were  present  in  alopecia  areata,  as  soon  as  Von  Sehlen’s  paper 
appeared,  jumped  incontinently  to  the  other  extreme  and  said  that  bacteria  were  pre- 
sent in  all  hairs. 

In  regard  to  the  existence  of  organisms  in  healthy  hairs,  Dr.  Thin  differs  from 
the  German  critics.  He  has  made  many  observations  (which  he  hopes  shortly  to  be 
able  to  publish)  which  show  that  no  such  organisms  are  present  in  ordinary  hairs  as 
he  has  described  in  hairs  in  alopecia  areata.  If  proper  precautions  are  taken  in 
purifying  the  scalp  and  in  extracting  the  hairs,  it  can  be  shown,  he  believes,  that 
normal  hairs  are  free  from  bacteria  in  that  part  of  the  shaft  which  is  in  the  corium. 

As  regards  the  value  of  Dr.  Robinson’s  observations,  which  Dr.  Thin  believes 
constitute  a great  discovery  as  regards  this  disease,  opinions  will  vary  according  to 
the  bias  of  different  observers  on  the  important  point  of  what  constitutes  sufficient 
evidence  that  an  organism  is  pathogenic.  Those  who  hold  that  we  are  not  entitled 
to  consider  an  organism  pathogenic  until  we  have  reproduced  the  disease  by  cul- 
tivated organisms  will  consider  that  the  point  is  not  proven  as  regards  this  organism, 
but  he  would  call  to  mind  the  fact  that  this  canon  is  not  held  in  universal  respect. 
Many  observers,  like  himself,  have  no  doubt  that  the  bacillus  of  leprosy  is  a patho- 
genic organism,  although  not  only  has  the  disease  not  been  produced  by  the  cul- 
tivated organism,  but  the  organism  has  not  yet  been  cultivated. 

He  would  remind  them  that  for  more  than  forty  years  trichophyton  tonsurans  was 


268 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


almost  universally  accepted  as  the  cause  of  Ringworm,  although  the  fungus  had  never 
been  cultivated  at  all.  Even  now  he  is  not  aware  that  authentic  observations  are  to 
be  found  in  literature  that  show  that  ringworm  of  the  head  or  of  the  body  has  been 
produced  by  cultivations  of  trichophyton.  No  one  doubts  that  tinea  versicolor  is  pro- 
duced by  the  fungus  that  is  always  found  among  the  scales  of  that  eruption,  but  the 
fungus  has  never  been  cultivated,  far  less  has  the  disease  been  reproduced  by  the 
cultivated  fungus. 

Dr.  Robinson  has  shown  that,  in  a series  of  cases,  in  the  diseased  areas  of  alo- 
pecia areata  one  and  the  same  coccus  is  always  present,  leading  to  obstruction  of  the 
lymphatic  vessels  and  blood  vessels,  and  causing  changes  which  explain  hitherto 
unexplained  features  of  the  disease.  Those  who  believe  that  the  bacillus  of  leprosy 
is  pathogenic,  and  that  the  fungi  of  favus,  ringworm  and  tinea  versicolor  are  respec- 
tively pathogenic  in  these  diseases,  are,  he  contended,  logically  bound  to  accept  Dr. 
Robinson’s  conclusions. 

The  paper  he  considered  to  be  one  of  enormous  interest,  and  to  mark  the  begin- 
ning of  a new  epoch  in  the  study  of  this  important  malady,  and  he  congratulated  the 
author  and  the  Section  on  the  fact  that  they  had  had  a paper  of  such  great  value 
brought  before  them. 

Dr.  Zeisler,  of  Chicago,  agreed  with  Dr.  Unna  that  it  would  take  a long  time 
to  bring  about  a union  of  the  two  opinions  regarding  the  cause  of  alopecia  areata,  as, 
so  far,  there  are  strong  proofs  in  both  directions.  When  microorganisms  are  found 
after  such  careful  methods  of  investigation  as  Dr.  Robinson  has  made,  one  must 
believe  in  the  causal  relation  of  the  same  to  the  disease.  It  is  only  natural  that 
every  observer  will  form  an  opinion  for  himself  from  the  nature  of  the  majority  of 
cases  which  he  has  observed.  He  related  two  cases  in  which  the  neurotic  origin 
appeared  unmistakable.  One  was  in  a case  of  exophthalmic  goitre  (Basedow’s  dis- 
ease) ; the  other  followed  a stroke  upon  the  head. 

Dr.  Henry  J.  Reynolds  regarded  the  paper  as  a most  admirable  one,  but  said 
that,  while  the  resume  of  the  arguments  that  had  been  previously  advanced  for  and 
against  the  parasitic  theory  were  essential  and  ably  presented  by  the  essayist,  they 
did  not  decide  anything  positively,  either  in  favor  of  the  neurotic  or  the  parasitic  ori- 
gin of  the  disease.  In  fact,  to  his  mind,  he  thought  the  balance  of  evidence  thus 
afforded  was  rather  in  favor  of  the  tropho-neurotic  origin.  The  pathological  con- 
dition shown  by  Dr.  Robinson  was,  however,  conclusive,  certainly,  so  far  as  the  cases 
embraced  under  his  investigations.  Then  granting  that  the  pathological  conditions 
thus  shown  be  established,  the  final  question  as  to  the  cause  of  that  condition  remains 
yet  to  be  settled.  Could  that  condition  be  produced  by  a neurotic  trouble  ? That  it 
is  produced  by  the  microorganisms  seen  is  not  proven,  as  it  was  still  a question  with 
many  whether  those  bodies  are  the  cause  or  the  consequence  of  the  disease.  Cer- 
tainly the  almost  established  non-contagious  character  of  the  disease  would  be 
opposed  to  the  parasitic  theory  ; and  until  the  disease  be  reproduced  by  culture  and 
inoculation  it  could  not  be  conclusive.  The  arguments  rehearsed  by  the  essayist, 
however,  certainly  show  this  much,  that  the  parasitic  trouble  or  origin,  if  at  all,  is 
confined  to  the  interstices  of  the  true  skin  rather  than  to  the  hair  structure  or  fol- 
licles as  has  been  claimed  by  other  supporters  of  the  parasitic  theory. 

In  regard  to  treatment,  if  the  disease  be  the  result  of  a parasite  within  the  struc- 
ture of  the  true  skin,  he  would  very  strongly  urge  a trial  of  the  treatment  which  he 
proposed  for  favus,  etc.  in  his  paper  read  the  day  previous,  viz. , the  application  of 
the  parasiticide  with  the  positive  electrode  of  a galvanic  battery.  There  can  be  no 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


269 


possible  doubt  but  that  a medicinal  substance  applied  in  this  way  will  permeate  all 
the  structures  for  a considerable  distance  beneath  the  surface.  The  procedure  would 
not  only  be  beneficial  by  possibly  curing  the  disease,  but  would  tend,  if  successful,  to 
show  a parasite  to  be  the  true  cause  rather  than  a tropho-neurosis. 

Dr.  Ravogli  said  he  had  found  small  corpuscles  resembling  microorganisms  in 
the  epidermis,  around  the  hairs,  and  in  the  hair  follicles  and  hair  shaft.  He  related 
the  case  of  a lady  who  complained  of  an  itching  in  a circumscribed  spot,  shortly  after 
which  a spot  of  alopecia  areata  occurred  at  this  point.  He  related  the  clinical  his- 
tories of  several  other  cases. 

Dr.  Knaggs  related  a case  of  general  alopecia  following  a severe  dental  neuralgia. 
The  perchloride  of  mercury,  pilocarpine  in  large  doses,  the  extraction  of  the  teeth, 
were  without  avail.  Faradism  finally  resulted  in  a cure.  After  this  the  patient  had 
marked  anaesthesia  of  the  whole  body,  especially  of  the  scalp.  A strong  current  was 
necessary  to  make  him  feel  the  application.  Afterward  he  suffered  intense  agony 
when  the  electricity  was  given,  even  in  weak  current.  In  other  cases  he  had  used 
twenty  per  cent,  oleate  of  mercury  with  benefit. 

Dr.  Robinson,  in  closing  the  discussion,  regretted  that  more  attention  had  not 
been  directed  to  the  anatomical  changes  in  the  skin  in  considering  the  question  of 
etiology.  Such  conditions  as  are  present  could  not  be  the  result  of  a tropho-neurosis. 
He  admitted  an  alopecia  from  neurotic  disturbance,  but  not  the  usual  alopecia  areata. 
Inoculation  with  negative  results  could  lead  to  false  conclusions,  as  shown  in  many 
undoubted  parasitic  diseases. 


A UNIQUE  CASE  OF  MELANOSIS  OF  THE  SKIN. 

UN  CAS  UNIQUE  DE  MELANOSE  DE  LA  PEAU. 

EIN  EIGENARTIGER  FALL  VON  MELANOSIS  DER  HAUT. 

BY  A.  R.  ROBINSON,  M.D., 

Of  New  York,  N.  Y. 

The  patient,  a lady,  twenty-one  years  of  age,  a resident  of  the  South,  came  to  me 
with  the  following  history  : — 

When  about  two  or  three  years  of  age,  there  appeared  a faintly  visible,  dark  spot  on 
the  lid  of  her  right  eye.  No  pain  or  sickness  attended  the  appearance  of  this  discolora- 
tion, but  ever  since  first  noticed,  it  has  been  slowly  and  gradually  spreading.  It  was 
especially  noticeable  on  the  face  at  eight  years  of  age. 

At  no  time  has  she  suffered  from  pain,  numbness  or  tingling  in  the  affected  parts. 
A few  months  ago  she  had  an  attack  of  measles,  and  had  chicken-pox  when  an  infant, 
but  never  had  scarlatina.  She  has  lived  in  a malarious  district,  and  has  suffered  from 
chills  and  fever  for  ten  years,  although  her  general  health  and  nutrition  are  good. 

On  examination  I found  that  the  lesion  consisted  primarily  of  pin-point,  non-ele- 
vated, dark  spots  of  a bluish-black  color,  which  did  not  disappear  on  pressure.  They 
were  not  covered  by  scales,  and  resembled  little  freckle  spots;  being  irregular  in  shape 
and  widely  separated  at  the  periphery  of  the  patch,  approaching  each  other  more  and 
more  closely  toward  the  centre,  until,  finally,  an  area  of  general  complete  pigmenta- 
tion was  formed,  in  which  no  spots  were  observable,  only  a bluish  discoloration  with  a 
tinge  of  black. 


270 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  entire  right  upper  eyelid  was  occupied  by  a diffuse,  non-scalirig  patch,  which 
appeared  perfectly  normal  to  the  touch  and  exhibited  no  atrophy,  no  dilated  blood 
vessels,  or  anything  abnormal,  except  the  pigmentation.  The  lid  was  not  retracted. 

The  pigmentation  was  also  present  below  the  eye  and  on  the  right  side  of  the  fore- 
head, not  extending  to  the  median  line,  and  passing  two  inches  into  the  hairy  scalp  ; 
another  patch  was  found  at  the  right  angle  of  the  mouth.  Besides  this  external  dis- 
coloration, there  was  also  a darkening  of  the  inner  side  of  the  right  cheek  and  traces  on 
the  mucous  membrane  of  the  left,  while  the  roof  of  the  mouth  presented  one  dark 
spot  the  size  of  a pea.  It  appeared  as  if  about  to  commence  on  the  conjunctiva  of  the 
left  eye. 

All  the  parts  thus  affected  are  merely  discolored,  and  display  no  excrescences,  nor 
prominences,  nor  anything  otherwise  abnormal.  The  case  was  submitted  to  Professors 
Webster  and  Starr,  of  the  New  York  Polyclinic,  for  an  examination  of  the  eye  and 
nervous  apparatus. 

The  following  is  Dr.  Webster’s  report: — 

“ Both  eyes  are  ophthalmoscopically  normal.  Vision  = §#.  Hm.  Both  ears 
are  normal  as  far  as  inspection  goes.  The  hearing  of  the  left  is  normal  (§§),  and,  as 
nearly  as  I can  determine,  the  right  is  totally  deaf.  There  are  no  evidences  of  aural 
catarrh,  and  all  the  symptoms,  as  well  as  the  history,  point  to  nervous  deafness.  The 
deafness  was  first  noticed  when  she  was  six  or  eight  years  of  age,  and  may  have  existed 
from  birth.” 

Dr.  Starr’s  examination  showed  “that  the  tactile,  pain  and  faradic  sensibility  was 
normal  and  equal  on  both  sides  over  the  temple  and  eyelids,  at  which  points  the  pig- 
mentation was  most  intense.  There  was  a very  slight  difference  perceived  between  the 
two  sides  to  the  temperature  tests,  both  hot  and  cold  sensations  being  very  slightly 
more  acute  on  the  pigmented  side.” 

Microscopical  examination  of  the  sections  of  the  skin  was  made  by  Dr.  Louis  Heitz- 
man,  who  made  the  following  report : “ The  epithelial  layer  is  of  normal  thickness, 
covered  with  a thin  epidermal  layer  which  is  not  pigmented,  while  all  the  layers  of  the 
rete  mucosum  are  made  up  of  epithelia  filled  with  dark  brown  pigment  granules. 
This  feature  is  different  from  the  pigmentation  observed  in  Addison’s  disease,  where 
the  pigment  granules  are  seen  only  in  the  lower  row  of  the  columnar  epithelia.  The 
pigmentation  involves  also  the  epithelia  of  the  outer  root  sheath  of  the  hair,  where  it 
is  lighter  than  on  the  surface  of  the  skin.  The  papillary  layer  is  unchanged  and  its 
fibrous  connective  tissue  free  from  pigmentation.  A short  distance  beneath  the  rete 
mucosum,  however,  a large  number  of  pigmented  corpuscles  are  seen,  which,  with 
higher  powers,  are  seen  to  be  protoplasmic  bodies  beneath  the  bundles  of  the  derma, 
more  or  less  crowded  with  or  transformed  into  a dark,  brown-red  pignfeut.  Iu  some 
places  nearly  all  the  protoplasmic  tracts  are  pigmented,  in  other  parts  only  a limited 
part  of  the  protoplasma.  In  the  former  instance  there  is  a dark,  red-brown  reticulum, 
in  the  latter  instance,  dark,  red-brown,  star-shaped  formations.  Both  features  are  due 
to  the  pigment  forming  only  in  the  protoplasma  between  the  bundles  of  connective 
tissue.  The  epithelia  of  sweat  glands  and  their  ducts  are  also  pigmented,  though 
lighter  than  the  outer  root  sheath  of  the  hair,  and  diffused  without  a marked  disposition 
of  pigment  granules.  The  same  is  the  case  with  the  epithelia  of  the  sebaceous  glands 
when  they  are  not  transformed  into  fat.  The  pigmentation  invades  the  whole  derma 
into  the  subcutaneous  tissue.  The  fat  tissue  of  the  latter  is  free  from  pigmentation.” 

The  case  is  reported,  as  I believe  there  is  not  a similar  ease  on  record.  The  situa- 
tion of  the  pigment,  the  manner  of  spreading  of  the  disease  and  the  maeroscopically 
normal  character  of  the  skiu  in  all  respects,  except  the  pigmentation,  furnish  a clinical 
picture  not  met  with  in  any  form  of  melanosis  hitherto  described. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


271 


DE  L’ ELEPHANTIASIS  DES  ARABES  CHEZ  LES  ENFANTS. 

ELEPHANTIASIS  ARABUM  AMONG  CHILDREN. 

UBER  ELEPHANTIASIS  ARABUM  BEI  KINDERN. 

PAR  LE  DR.  MONCORVO, 

Rio  de  Janeiro,  Brazil. 

Malgr6  tons  les  travaux  publics  jusqu’it  present  sur  l’elephantiasis  des  Arabes, 
affection  predominante  dans  les  climate  tropicaux,  plusieurs  points  de  son  histoire 
demandent  encore  de  nouvelles  recherches. 

Nous  n’avons  en  ce  moment  en  vue  que  d’eclairer  une  question  de  l’etiologie  de  la 
maladie,  celle  qui  se  rapporte  a sa  frequence  pendant  les  premieres  epoques  de  la  vie. 

La  presque  totalite  des  observateurs  qui  out  travaille  a l’etude  de  l’elephaneie  ont 
eu  constater  dans  leurs  recherches  des  cas  plus  ou  moins  avances  dans  leur  evolution, 
c’est-k-dire  qu’il  s’agissait  de  malades  ayant  dej a depasse  l’epoque  de  la  puberte,  ou  du 
moins  l’ayant  dej;\  atteinte. 

D’une  fa9on  generale  on  peut  affirmer  que  les  faits  recueillis  par  ces  observateurs  se 
rapportaient  h des  individus  arrives  a I’ age  adulte. 


Elephantiasis  des  Arabes  conggnitale. 

Ils  se  bomaient,  pour  ainsi  dire,  l’examen  des  cas  les  plus  frappants,  tantot  par 
leur  developpement  considerable,  tantot  par  l’etendue  du  mal. 

II  parait  que  ces  medecins  s’inquietaient  fort  peu  de  l’epoque  de  l’invasion  de  la 
maladie,  ne  pretant  d’attention  qu’aux  caractkres  et  au  sifege  de  l’affection. 

Cela  nous  explique  peut-etre  le  silence  garde  jusquA  une  certaine  6poque  par  les 
auteurs  qui  ont  ecrit  sur  ce  sujet,  et  l’avis  emis  plus  tard  par  d’autres  sur  la  rarete  d’une 
telle  affection  avant  la  puberte. 

C’est  ainsi  que  Ernest  Godard,  qui  a eu  l’occasion  d’etudier  largement  cette  maladie 
pendant  son  voyage  a travers  l’Egypte  et  la  Palestine,  a ecrit  que  “jamais  la  maladie 
n’arrive  avant  Page  adulte,”  en  ajoutant  plus  loin  qu’il  n’existe  pas  un  seul  cas  obser- 
ve chez  V enfant. 

Le  Dr.  Mohamed-Aly-Bey,  qui  a fait  une  excellente  these  sur  ce  sujet,  s’est  exprime 
comme  il  suit,  par  rapport  il  l’epoque  de  la  vie  dans  laquelle  la  maladie  se  pr6sente  : 
“ L’elephantiasis  peut  se  developper  di*s  Page  de  15  ans  chez  les  ganjons  et  de  12  chez 
les  filles  ; il  peut  se  rencontrer,  mais  tres  rarement,  avant  cette  epoque,  ainsi  a Page  de 
huit  ans,  (Dr.  Mohamed-Aly-Bey)  h Page  de  10  ou  12  ans. 

On  peut  dire  d’une  manikre  generale  que  Page  le  plus  propice  pour  le  developpe- 
ment de  cette  maladie  est  entre  15  et  20  ans,  6poque  a laquelle  s’accomplit  un  revolu- 
< tion  gen6rale  dans  l’organisme  chez  l’homme  et  chez  la  femme. 


272 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Hebra  affirme  que  cette  maladie  est  tres  rare  avant  la  pubertE.  I) 'apres  Duchas- 
saing  la  maladie  ne  se  developperait  jamais  avant  l’age  de  8 it  10  ans,  ajoutant  meme 
que  c’etait  une  exception. 

Cloquet,  Gibert,  Alfonseca,  BroquEre  considerent,  pour  leur  part,  la  maladie  comme 
une  curieuse  exception  avant  la  puberte  Duhring  partage  tout-it-fait  cette  maniere  de 
voir. 

Nous  pourrions  ajouter  bieu  d’autres  citations  it  l’appui  de  cette  conclusion  acceptee 
par  la  presque  total ite  des  observateurs,  que  P elephantiasis  inconnu  chez  les  enfants  du 
premier  dge,  est  extremement  rare  avant  Page  de  la  puberte. 

C’cst  it  cette  opinion,  passee  comme  une  vEritE  absolue  au  milieu  de  tant  de  travaux 
publics  sur  cette  terrible  affection,  que  nous  pretendons  nous  opposer,  en  nous  appuyant 
sur  une  periode  d’observation  de  plus  de  200  cas. 

Apres  etre  arrive  it  la  conviction  formelle  de  la  presence  de  P Elephantiasis,  meme 
cbez  les  plus  jeunes  enfants,  nous  avons  precede  it  de  nouvelles  recherches  bibliogra- 
phiques  a ce  sujet,  et  nous  avons  retrouve  quelques  faits  Epars  dans  les  archives  de  la 
science,  qui  viennent  corroborer  les  resultats  de  notre  observation  personnelle.  Tels 
sont  ceux  appartenant  it  Leon  Labbe  (13  mois),  Gueniot  (2  ans),  Lannelongue,  Th. 
Beck  (14  ans),  Bardeleben,  Demme  Weber,  V.  Ruge  (9  ans). 

Waring,  sur  un  total  de  945  cas  d’ElEphantiasis  recueillis  par  lui  dans  les  archives, 
rencontra  729  cas  observes  entre  26  et  60  ans,  139  entre  5 et  25  ans,  et  77  apres  la  60e 
annEe. 

En  recbercbant  l’epoque  de  l’apparition  de  la  maladie  il  t-rouva  16  cas  chez  de  tout 
jeunes  enfants,  7 cas  avant  la  5e  annEe  et  133  entre  6 et  10  ans. 

Cela  donne  done  un  total  de  156  cas  observEs  chez  la  premiere  et  la  deuxiEme  en- 
fance  soit  16  pour  100. 

Nous  avons  EtE  it  meme  de  recueillir  45  cas  d’elEphantiasis  dont  28  furent  rencon- 
tres chez  des  jeunes  sujets,  et  17  observEs  chez  des  adultes  qui  avaient  EtE  affectEs  dans 
leur  enfance. 

Au  milieu  de  ceux  du  premier  groupe  nous  ferons  mention  toute  particuliEre  de 
quelques  faits  fort  dignes  d’etre  relevEs  par  la  prEcocitE  exceptionnelle  de  l’invasion  du 
mal. 

Observation  i. — Dans  ce  cas  il  s’agissait  d’un  nonveau-ne  de  15  jours,  it  peine 
presentE  dans  notre  service  le  23  Septembre,  1884.  Ce  garejon,  pEsant  3 kil.  500,  por- 
tait  sur  la  region  hypogastrique  et  pubienne  les  signes  trEs  caractEristiques  de  P Ele- 
phantiasis it  son  dEbut,  la  maladie  Etant  survenue  it  une  lymphangite  pEri-ombElicale 
apparue  vers  le  quatriEme  jour  de  la  naissance. 

Nous  osons  croire  qu’aucun  cas  pareil  ne  fut  jamais  publiE  pour  ce  qui  touche  l’E- 
poque  de  l’apparition  de  1’ElEphantiasis. 

Observation  ii. — Ce  fait  est  relatif  it  un  gartjon  figE  it  peine  de  quatre  mois  qui 
fut  amenE  it  notre  service  le  11  Juin,  1883. 

Il  avait  EtE  vaccinE  le  5 Juin,  et  quatre  jours  aprEs  il  lui  Etai*t  survenu  une  lym- 
phangite aux  deux  bras. 

Celle  du  bras  gauche  termina  vite  par  la  rEsolution,  mais  le  bras  et  l’avant-bras 
droits  devinrent  ElEphantiasiques.  Ce  gar^on  fut  guEri  au  bout  d’un  mois  au  moyen 
de  la  compression  Elastique. 

Observation  hi.  — Il  s’agit  d’une  tillette,  figEe  de  9 mois,  portant  des  manifestations 
tres  accusEes  de  la  syphilis  liErEditaire. 

Un  mois  avant  l’admission  de  cette  enfant,  elle  avait  EtE  atteinte  d’une  lymphangite 
it  la  jarnbe  gauche. 

Cette  lymphangite  avait  EtE  la  consEquence  de  l’rritatiou  que  l’entant  avait  deter- 
minEe  au  pourtour  d’uue  pustule  siEgeant  it  la  mallEole  interne  de  la  jambe  gauche  en 
s’y  grattant  forteineut. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY.  273 


L'cedfeme  envahit  la  jambe  jusqu’it  la  region  inguinale  ; elle  devint  douloureuse 
dans  toute  son  etendue,  la  peau  se  montra  chaude  et  rougeatre. 

Elle  a eu  en  merue  temps  uue  reaction  febrile  qui  dura  trois  jours.  Au  bout  de 
quelques  jours  les  phenomenes  de  reaction  locale  s’amendferent,  et  ensuite  le  tissu 
sous-cutan6  de  la  totality  de  ce  membre  fut  envahi  par  le  processus  616phantiasique. 

Observation  iv. — Le  premier  Mai,  1886,  on  nous  amena  it  la  Polyclinique  une 
lillete  de  13  mois,  laquelle  it  partir  du  septifeme  mois,  avait  ete  atteinte  de  lymphan- 
gites  a la  jambe  gaucbe. 

Aussi  il  lui  survinrent  des  accfes  de  fievre  intevmittente  repetes. 

Quatre  mois  aprfes  la  premiere  crise  de  lymphangite  la  jambe  gauche  commen9a  it 
etre  envahie  par  le  processus  el6phantiasique. 

Les  dimensions  des  deux  jambes  eta’ent  celles-ci : — 

Jambe  Droite.  Jambe  Gauche. 

Au  tiers  sup.  16J  cent.  Au  tiers  sup.  18  cent. 

Au  tiers  moyen.  17  cent.  Au  tiers  moyen.  19  cent. 

Au  tiers  inf.  12i  cent.  Au  tiers  inf.  13i  cent. 


En  resume  le  releve  d’apres  Page  des  cas  appartenant  au  premier  groupe  est  le  sui- 


A l’ago  de  15 

jours, 

i 

cas. 

A Page  de 

8 

ans, 

9 

3 

cas. 

a 

tt 

it 

4 

mois, 

i 

n 

ft 

n 

9 

n 

2 

a 

ft 

a 

9 

a 

i 

it 

li 

a 

10 

a 

2 

it 

if 

u 

13 

it 

i 

a 

it 

it 

11 

n 

4 

tt 

a 

a 

2 

ans, 

2 

a 

it 

it 

12 

tt 

2 

tt 

a 

n 

3 

a 

2 

it 

a 

it 

13 

a 

3 

a 

a 

n 

7 

n 

1 

n 

it 

tt 

14 

t( 

3 

tt 

Total 

9 

Total 

28 

cas. 

Au  point  de  vue  du  sexe,  13  appartenaient  au  sexe  masculin  et  15  au  feminin. 
Quant  it  la  race  : 23  blancs  et  5 metis. 

D’apres  le  siege  de  l’affection  : — 

10  cas. 

Bras  droit,  1 cas.  Jambe  droite,  13  “ 

Jambe  gauche,  7 “ Les  deux  jambes,  4 “ 

Jambe  et  main  gauches,  1 “ Region  hypogastrique  et  pubienne,  1 “ 

Face  1 “ 


Total  10 


Total  28  cas. 


En  procedant  de  la  sorte  pour  les  cas  compris  dans  le  deuxieme  groupe,  nous  aurons: 
D’apres  l’age  des  malades  it  l’epoque  du  premier  examen  : — 


11 

cas. 

A Page  de  15  ans, 

3 

cas. 

A Page  de  20  ans, 

1 

a 

“ 16  “ 

3 

a 

“ “ 22  “ 

2 

it 

it  a 27  t* 

2 

tt 

tt  tt  28  “ 

1 

a 

“ “ 18  “ 

2 

tt 

“ “ 29  “ 

1 

a 

a a 29  “ 

1 

tt 

“ tt  44  « 

1 

tt 

Total 

11 

Total 

17  cas. 

D’apr&s  le  sexe  : — 

Quant  it  la  race 

: — 

Masculin,  12  cas. 

Blancs,  14  cas. 

Feminin,  5 “ 

Metis,  3 “ 

Total  17  cas. 

Total  17  cas. 

Par  rapport  au  sikge  : 

Jambe  droite,  5 cas. 

Jambe  gauche  2 “ 

Les  deux  jambes,  5 “ 

Total  12 


12  cas. 

Jambo  et  cuissc  droites,  2 “ 

Jambe  et  cuisso  gauches,  1 “ 

Les  deux  membres  thoraciques  et  les  deux  jambes,  1 “ 
Scrotum,  fourreau  de  la  verge  et  jambe  gauche,  1 “ 


Vol.  IV — 18 


Total  17  cas. 


274 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


En  les  groupant  d’aprhs  Page  auquel  Elephantiasis  a fait  son  apparition,  nous  avons 
le  tableau  ci-dessous. 


A l’Uge  de  2 ans,  1 cas. 

II  II  It  2 11 

it  it  § it  | it 

Total  4 


4 cas. 

A 1’S.ge  do  6 ans,  2 cas. 

it  ii  g it  b a 

ii  a if  u g it 

“ “ 12  “ 3 “ 

Total  17  cas. 


Enfin,  si  nous  reunissons  les  deux  groupes  en  les  clasaant  selon 
fait  son  apparition,  nous  aurons  le  resultat  suivant : — 


A Page 

(le 

15 

jours, 

1 

cas. 

A l’age  de 

7 

ans; 

u 

(( 

4 

mois, 

1 

a 

ii 

ii 

8 

a 

u 

u 

9 

u 

1 

it 

ii 

a 

9 

a 

u 

u 

13 

(( 

1 

K 

it 

it 

M) 

a 

(( 

(( 

2 

ans, 

3 

ii 

ii 

a 

11 

a 

it 

u 

3 

u 

4 

ii 

ii 

a 

12 

a 

u 

(( 

5 

i( 

1 

ii 

ii 

a 

13 

a 

u 

u 

6 

u 

2 

it 

ii 

a 

14 

a 

Total  14  Total 


l’age  oh  l’affection  a 

14  cas. 

1 “ 

8 “ 

2 “ 

2 “ 

7 “ 

5 “ 

3 “ 

3 “ 

45  cas. 


Ce  chiffre  fut  retrouve  sur  an  total  de  157  cas  d’ Elephantiasis  ce  qui  donne  une  pro- 
portion de  28  pour  100. 

En  ajoutant  aux  cas  ci-dessus  ceux  reeueillis  a la  litterature  etrangtre,  nous  aurons 
un  total  de  1110  parrni  lesquels  209  survenus  pendant  l’enfance,  soit  une  proportion  de 
18  pour  100. 

Mais  le  trait  le  plus  interessant  de  cette  communication  c’est  le  fait  tout  derniere- 
ment  recueilli  dans  notre  service  et  que  nous  signalerons  a part  it  cause  de  sa  singularity, 
car  il  s’agit  d’un  cas  d’elephantiasis  developpee  pendant  la  vie  intra-uteri ne. 

Or,  aucun  fait  analogue  n’existe  dans  les  archives  de  la  science,  que  nous  le  sa- 
chions. 

Le  20  Septembre  de  1886,  on  nous  amena  it  notre  service  it  la  Polyclinique  une  fil- 
lette,  agee  de  quatre  mois,  et  issue  de  parents  italiens. 

La  mere  accusait  des  accidents  veneriens  et  disait  avoir  eu  des  acchs  de  fievre  palus- 
tre  pendant  la  gestation  de  cette  enfant  qui  etait  la  deuxieme. 

Elle  n’avait  ponrtant  subi  aucune  contusion,  ni  avait  fait  aucune  chute  pendant  ce 
temps- lit. 

Le  phre  bien  constitue,  avait  ete  atteint,  vers  Janvier,  1886,  par  une  crise  de  lym- 
phangite  aux  deux  jambes  accompagnee  d’une  reaction  febrile  intense. 

L’enfant  jouissant  d’une  sante  generate  trhs  reguliere  avait  le  poids  de  6 kilogram- 
mes et  mesurait  56  cents,  d’extentiou.  La  mere  nous  la  presenta  dans  le  but  de  la 
faire  soigner  d’une  malformation  des  deux  pieds  et  de  la  main  gauche  qu’elle  avait  con- 
statee  quelques  moments  aprhs  son  accouchement. 

Par  l’examen  nous  avons  reconnu  une  augmentation  considerable  du  volume  des 
deux  pieds,  cette  augmentation  etant  dfle  au  processus  61ephantiasique,  developpe  t;mt 
sur  la  region  dorsale  que  sur  la  plantaire,  depuis  la  racine  des  orteils  jusqu’il  la  r(*gion 
malleolaire. 

Les  tissus  de  la  region  affcctee  offraient  assez  de  resistance  it  la  pression  en  ayant  la 
consistance  du  caoutchouc. 

La  peau  qui  la  recouvrait  etait  lisse,  parsem6e  de  petites  vesicules  et  de  papules; 
sa  coloration  etait  normale  sur  la  face  dorsale  et  un  pen  rougeatre  ii  la  face  plantaire. 
La  partie  dorsale  etait  s6par6e  de  la  plantaire  par  un  sillon  partaut  du  talon  jusqu’au 
niveau  des  articulations  metatarso-phalangiennes. 

II  n’y  avait  il  constater  aucune  modification  par  rapport  it  la  seusibilit6  ni  par  rap- 
port it  la  temp6rature. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


275 


Le  pied  gauche  6tait  plus  volumineux  que  celui  du  ciit6  droit,  comme  on  voit 
d’apres  les  dimenssions  suivantes  : — 

Hauteur  de  la  partie  moyenne  du  pied  droit,  4]  cents.;  et  celle  du  pied  gauche,  5 
cents.;  circonference  du  pied  droit  a,  ce  niveau,  15  cents;  et  celle  du  cote  gauche,  16 
cents;  l’axe  antero-posterieur  du  pied  droit  10  cents.;  et  celui  du  pied  gauche,  101 
cents.;  circonference  de  la  region  plantaire  du  pieds  droit  24  cents.;  et  celle  du  pied 
gauche  25  cents. 

A la  main  gauche  l’clephantiasis  avait  envahi  presque  exclusivement  les  doigts  et  y 
etait  peu  accusee. 

L’enfant  fut  soumise  t\  l’usage  de  1’iodure  de  potassium  ainsi  qu’;\  la  compression 
elastiqne  et  it  l’electrotherapie. 

Ce  cas  est,  notre  avis,  unique  dans  la  science,  car  nous  n’avons  pu  trouver  d’autre 
analogue  publie  jusqu’ici. 

De  tout  ce  qui  prdcfede  nous  devons  conclure  : 

1.  Que  l’elephautiasis  des  Arabes  peut  se  developper  meme  pendant  la  vie  intra- 
uterine. 

2.  Que  cette  affection  peut  etre  retrouvee  dans  toute  le  periode  de  l’enfance  au  con- 
traire  de  ce  qu’on  avait  cru  jusqu’ici. 


FOUR  RECENT  CASES  OF  MYCOSIS  FUNGOIDES  OF  ALIBERT, 
WITH  AN  EXAMINATION  AS  REGARDS  THE  EXISTENCE  OF 

PARASITES. 

QUATRE  CAS  RECENTS  DE  MYCOSE  FONGOIDE  D’ALIBERT  AVEC  UN  EXAMEN 
CONCERNANT  L’EXISTENCE  DES  PARASITES. 

VIER  NEUE  FALLE  DER  MYCOSIS  FUNGOIDES  ALIBERTS,  NEBST  UNTERSUCHUNGEN  UBER 

DIE  ANWESENHEIT  VON  PARASITEN. 

BY  PROF.  THOMAS  DE  AMICIS, 

Of  Naples. 

In  the  year  1882,  under  the  title  of  “ Dermo-lympho-adenoma-fungoides,”  I pub- 
lished two  cases  of  that  malady,  which  had  been  described  under  the  name  of  “ My- 
cosis fungoides  of  Alibert.”  In  the  following  years  the  scientific  literature  has  been 
enriched  with  other  valuable  works  on  the  same  subject,*  and  there  has  been  much 
debate  both  as  to  the  nomenclature  to  be  adopted  for  this  malady  and  as  to  the  anatomo- 
pathologic  nature  of  the  process  and  the  relation  which  it  might  bear  to  other  neo- 
plastic forms. 

In  these  last  few  years  I have  had  the  rare  opportunity  of  studying  four  new  cases 
of  this  affection ; and  I think  it  proper  to  place  my  observations  before  the  enlightened 
judgment  of  my  learned  colleagues  in  the  Section  of  Dermatology  and  Syphilography 
of  the  International  Medical  Congress  of  Washington. 


* “A  Treatise  on  the  Diseases  of  the  Skin,”  published  by  Ziemssen,  with  articles  by  Aus- 
pitz,  Neisser  and  Babfis  (1883-1884).  “A  Contribution  to  the  Knowledge  of  the  Tumors  of  In- 
flammatory Granulations  (granuloma  sarcomatode  of  the  skin),”  by  R.  Naether,  Dentches  Arch, 
f.  Klin.  Med.,  1883.  “ On  the  Mycosis  Fungoides,”  by  P.  Fabre,  Gax.-mSd.  de  Paris,  Nos.  5, 

6,  7,  35,  36,  1884.  E.  Besnier,  Ann.  de  Dermat.  et  de  eyphilig.,”  p,  37,  1884.  “On  a New 


276 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


CASE  I. — MYCOSIS  FUNGOIDES  OF  ALIBERT. 

Diagnosis. — Julius  Romualdo,  of  Roccapiemonte,  aged  sixty-nine  years,  a priest. 
He  does  not  present  anything  remarkable  in  his  antecedents,  and  assures  us  that  for 
the  last  fourteen  years  he  has  always  enjoyed  perfect  health.  His  actual  cutaneous 
disease  began  about  two  years  ago,  after  a feeling  of  pain  in  different  parts  of  his  body, 
beginning  in  his  feet ; and  also  by  an  intense  itching,  together  with  an  almost  contem- 
poraneous appearance  of  erythematous  stains  on  the  trunk  and  on  the  extremities. 
These  stains,  gradually  coming  up  to  the  level  of  the  healthy  skin,  assumed,  after  the 
lapse  of  two  months,  in  some  places  particularly,  the  appearance  of  real  tuberous  excres- 
cences. Some  of  them  disappeared  spontaneously,  while  others  remained  there,  after- 
ward becoming  ulcerated. 

Examination  of  the  Cutaneous  Surface. — (See  Figs.  1,2.)  The  affection  is  spread  over 
the  trunk  and  the  extremities,  in  the  shape  of  deep-seated,  reddish  stains,  of  varying 
thickness,  of  noduli  and  tubera  ; some  reddish  and  some  of  a bright  red  color  ; partly 
ulcerated  (superficial  ulceration  on  a white-grayish  ground). 

In  some  points  can  be  observed  an  abundant  sero-lymphatic  exudation.  On  the 
posterior  part  of  the  trunk  the  middle  portion  is  sound,  the  affection  being  on  the  sides 
and  on  the  base  of  the  thorax,  and  spreading  over  the  scapular  region  and  over  the 
deltoid  externus.  It  extends  over  the  anterior  parts  of  the  trunk  and  over  the  surface 
of  the  abdomen.  It  is  less  developed  over  the  lateral  regions  of  the  trunk  on  the 
right  side.  On  all  these  points  are  to  be  seen  erythematous  stains,  diffused  and  a little 
elevated  (on  the  posterior  cervical  region  and  on  the  shoulders),  excrescences  in  the 
shape  of  tubera,  some  of  which  are  oblong  (3  to  4 by  2 cent.),  some  circular.  Some 
of  these  tubera  are  sound,  some  excoriated  and  others  deeply  ulcerated,  with  a white- 
grayish  base.  The  excoriations  result  partly  from  the  infiltration  proper,  and  partly 
from  the  scratching  caused  by  the  great  itching  which  torments  the  patient ; so  milch 
so,  that  excoriations  on  sound  tissue  may  also  be  seen  on  him,  covered  with  small  blood 
crusts.  On  the  anterior  part  of  the  abdomen,  at  the  sides  and  on  the  sacral  region,  the 
affection  is  diffused  and  of  a macular  and  infiltrated  form,  with  tuberous  ovoidal  eleva- 
tions scattered  over  it. 

The  Superior  Extremities. — On  the  internal  surface  of  the  right  forearm,  down  to  its 
inferior  third,  there  are  some  simple  macular  patches,  in  discrete  form,  while  on  the 
inferior  portion  of  the  left  arm,  from  the  armpit  down,  besides  some  erythematous  spots 
aud  flat  elevations,  there  are  also  to  be  seen  real  tuberous  excrescences,  three  to  four 
centimetres  long,  by  two  to  three  centimetres  broad,  as  well  as  larger  ones,  some  of 
which  are  ulcerated,  as  on  the  scapular  aud  axillary  regions. 

The  Inferior  Extremities. — These  are  less  affected  by  the  disease  than  the  superior 
ones.  The  right  thigh  is  affected  over  a very  large  extent  of  its  internal  surface,  while 
the  left  one  only  shows  the  disease  on  its  superior  fourth.  In  the  legs  the  disease  is  less 
advanced,  the  macular  form,  lightly  infiltrated,  being  there  prevalent.  Ichthyotic, 
whitish  scales  are  to  be  noticed  on  the  elbows  and  knees,  as  well  as  xeroderma  on  the 
legs. 

The  face  is  altogether  free  from  the  affection. 

The  enlargement  of  the  inguinal  lymphatic  glands  is  remarkable.  The  latero-cer- 
vical  ones,  too,  are  greatly  swollen,  especially  on  the  supra-clavicular  regions. 


Form  of  a Malady  of  the  Skin,  tho  Pernicious  Lymphodermy,”  by  M.  Kaposi,  Medic.  Jahrb. 
der  k.  Geaellechaft  der  Aerzte,  Wien,  1S85.  “ A Case  of  Granuloma  Fungoides,"  by  Auspitz, 

Vierteljahrach. f.  Dermal . und  Syph.,  1885.  “A  Study  on  the  Mycosis  Fungoides,”  by  Vidal 
and  Brocq,  France  Medicate,  Nos.  79  and  85,  1884.  “ Mycosis  Fungoides,”  by  Rindfleisch, 

Deutsche  med.  Wochenach.,  1885.  “Mycosis  Fungoides,”  by  Tilden,  Amer.  Dermatol.  Aatoc., 
August  26tli,  1885. 


F'gl 


Micosi  PtinjSoide  lav  I 

Clinics  Dermo  - sirilopad.ic  a della  R.Universita  di  Napoli 


T.Dc  Amiciu 


(liNCnn  klOMCITM  PM  I LA 


Fig  II 


Micas  i fungoirle  Tav.  II 

Clinic  a Derm.o-sifilopa.tica  della  R.Univereita  di  Napoli 

T l)e  Amicie 

*■  ti  O »•  Cl  TM  Mil  l|  * 


i 


SECTION  XIV — DERMATOLOGY  AND  SYPIIILOGRAPHY. 


277 


The  patient  complains  of  a very  violent  itching  and  of  a sensation  of  heat.  His 
sensibility  is  somewhat  exaggerated.  His  nutrition  is,  generally  speaking,  in  a very 
depreciated  state.  He  has  undergone  a course  of  iodide  of  potassium  and  of  liquor 
arsenicalis,  but  without  profit.  I cut  two  small  tumors  from  his  skin. 

April  12th,  1885.  I again  visited  the  patient.  He  is  in  the  same  condition  of 
health;  nay,  the  affection  has  even  progressed.  Many  of  the  excrescences  have  increased 
remarkably;  several  ulcerations  have  extended  still  further;  some  tuberous  elevations 
appear  to  have  become  fungoid,  and  resemble  in  size  the  small  berries  of  the  solatium 
li/copersicum.  The  sero-lymphatic  secretion  is  more  abundant.  The  patient  com- 
plains continually  of  a very  tormenting  itching,  principally  early  in  the  morning.  The 
analysis  of  the  urine  did  not  present  anything  worthy  of  notice.  That  of  the  blood 
did  not  show  any  increase  in  the  quantity  of  the  white  globules. 

May  15th.  The  patient  appears  in  the  following  state  of  health  : — 

The  Trunk  (a) — the  posterior  part. — In  the  left  scapulo-humeral  region  almost  all  the 
largest  nodules,  which,  so  far,  were  sound,  are  now  ulcerated  and  flattened,  the  bases 
of  the  ulcers  consisting  of  purulent  matter,  very  thick  and  of  a yellowish-black  color, 
similar  to  caseous  substance.  Other  smaller  nodules  are  fused  together,  so  as  to  form 
an  elevated  surface,  which  looks  like  a single  flat  and  reddish  stain,  about  six  centi- 
metres distant  from  the  vertebral  column,  where  it  ends  with  a raised  and  convex 
margin.  It  is  spread  all  over  with  small  nodules  and  granular  excrescences. 

In  the  homologous  region  nothing  else  is  to  be  observed  but  some  reddish  stains  of 
little  account. 

Along  the  median  line,  beginning  at  the  middle  of  the  vertebral  column,  a very 
large  reddish  stain  is  to  be  seen,  which,  as  it  descends,  becomes  broader,  till  it  reaches 
the  loins,  the  buttocks  and  the  lateral  region  of  the  abdomen,  over  which  it  extends. 
On  this  large  surface  there  appear  some  nodules , rather  flat  and  not  ulcerated,  having 
the  diameter  of  5 to  20  mm.  They  cause  insupportable  itching  to  the  patient. 

( b ) The  anterior  part. — The  whole  anterior  part  of  the  trunk,  some  points  excepted, 
is  altogether  liypersemic,  and  presents,  besides,  the  following  appearances: — 

On  the  left  mammillary  region  the  eruption  has  joined  with  that  of  the  left  humero- 
scapular  region;  although  it  is  now  in  a remarkable  state  of  involution,  for  the  existing 
nodules  are  ulcerated,  some  having  nearly  disappeared  and  some  being  very  much 
diminished  in  size  and  flat,  with  a very  limited  or  insignificant  amount  of  exudation. 
In  the  left  axillary  region  the  nodules,  which  at  first  reached  the  volume  of  an  hazel  nut, 
are  now  smaller,  with  less  extended  ulcerations  and  with  diminished  secretion.  A 
large  knot  existing  in  the  right  thoracic  region,  corresponding  with  the  parasternal  line 
of  that  side,  has  also  become  flat,  and  the  adjoining  ulcerations  are  in  a state  of  retro- 
gression. This  also  is  the  case  with  the  ulcerated  nodule  to  the  left  of  the  ensiform 
appendix. 

It  can  be  generally  said  that  in  the  anterior  region  of  the  trunk,  while  the  affection 
is  in  an  involutive  stage  where  it  had  reached  its  greatest  development,  it  has  now 
spread  to  points  where  it  did  not  exist  before,  under  the  form  of  hyperajmic  stains,  some 
of  which  are  also  somewhat  elevated. 

The  neck  and  the  nape  are  covered  with  large  reddish  stains,  having  margins  little 
or  not  at  all  elevated,  the  redness  of  which  disappears  under  the  pressure  of  the  finger. 
An  ulcerated  tubercle  existing  on  the  nape  is  healing  ; its  base,  at  first  excavated,  is 
now  getting  smoother,  the  edges  are  less  elevated;  its  secretion  has  nearly  disappeared. 
At  about  six  cent,  downward  from  the  middle  of  the  inferior  maxilla,  at  the  left  side, 
is  to  be  seen  a tubercular  elevation  of  the  diameter  of  two  cent.,  which,  as  the  patient 
relates,  had  disappeared  about  fifteen  days  before.  It  is  uow  gradually  increasing  in 
size,  being  covered  all  oyer  with  a gray-brownish  crust,  that  conceals  an  ulceration 
secreting  a small  quantity  of  purulent  fluid. 


27S 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  Face. — On  the  right  mastoid  region  is  to  be  seen  an  infiltrated  macula , causing 
much  itching.  Its  diameter  is  about  31  cent,  and  surrounds  a central  fovea  resulting 
from  a preexisting  ulceration  of  an  old  tubercular  knot. 

May  21st.  The  patient  is  again  seen.  The  following  modifications  in  his  condition 
are  to  be  noticed: — 

In  the  left  scapulo-liumeral  region  the  largest  nodules  remain  nearly  in  the  same  condi- 
tions as  before  observed,  while  the  single  pimples  of  the  elevated  margin  of  that  large 
stain,  of  the  size  of  a linseed  to  a small  pea,  have  likewise  undergone  an  ulcerative  pro- 
cess, getting  a crateriform  appearance,  with  a lard-like  bottom  and  with  a very  scanty  exu- 
dation. From  the  apex  of  some  of  them  there  exudes  a small  drop  of  a very  trans- 
parent liquid. 

The  ulcerations  of  the  left  mammillary  region  are  reduced  to  simple  erosions  with  a 
scanty,  serous  exudation.  The  nodule  on  the  left  side  of  the  ensiform  appendix  is 
remarkably  smooth,  and  the  neighboring  ulcerations  are  nearly  altogether  healed.  On 
the  contrary,  those  of  the  right  thoracic  region,  near  the  parasternal  line  of  that  side, 
appear  still  ulcerated  ; there  are  two  points  with  little  secretion  and  some  epithelial 
erosion  in  the  proximity. 

Starting  from  the  base  of  the  ensiform  appendix  at  the  right  side,  and  going  downward 
obliquely  as  far  as  the  right  mammillary  line,  along  the  curvature  of  the  eighth,  ninth 
and  tenth  costal  cartilages,  there  are  some  depressed  nodules,  each  nearly  the  size  of 
an  hazel  nut,  arranged  in  groups  and  having  nearly  all  ulcerations  with  irregular  mar- 
gins in  their  centre.  The  one  placed  more  on  the  outside  is  deeper  than  the  others  and 
has  a more  abundant  purulent  exudation,  of  a yellow-greenish  color. 

On  the  whole  abdominal  surface  there  are  here  and  there  elevated  stains  of  different 
dimensions — from  1 5 to  25  mm.  diameter.  They  are  separated  one  from  the  other  by 
portions  of  skin  far  less  hyperaemic  than  was  the  case  a week  before;  nay,  with  a nearly 
normal  color.  The  umbilical  fossa  is  flat,  and  in  its  place  there  is  a yellowish  crust,  a 
little  elevated,  which  covers  a superficially  ulcerated  surface.  By  pressing  the  cuta- 
neous tissue  between  the  fingers  at  that  point  one  has  the  sensation,  as  it  were,  of  a car- 
tilaginous tissue.  Moreover,  at  the  distance  of  about  six  centimetres  from  the  umbili- 
cus there  appears  a large  nodule,  very  much  flattened,  of  three  centimetres  diameter, 
ulcerated  and  covered  over  with  a very  thin  stratum  of  a dense  sero-purulent  exuda- 
tion. The  skin  of  the  lateral  regions  of  the  abdomen  (more  especially  at  the  right  side), 
the  skin  of  the  pubes,  that  of  the  anterior  and  internal  region  of  the  thighs,  is  all  uni- 
formly hypercemic  and  dry.  On  the  contrary,  the  skin  of  the  scrotum,  the  inguinal 
one,  that  of  the  scrotal  surface  of  the  perineum,  and,  finally,  that  of  the  fissure  of  the 
buttocks,  as  well  as  of  the  anal  region,  is  hypenemic  and  exudating. 

The  Superior  Extremities. — On  the  superior  extremity  at  the  right  side  there  are  two 
infiltrated  stains.  The  first  occupies  a larger  extent  of  tissue  than  the  other,  and  goes 
from  the  inferior  third  of  the  arm  to  the  superior  third  of  the  forearm,  taking  up  the 
whole  curvature  of  the  elbow.  It  bus  an  ulcerated  tubercle  in  its  centre.  The  other 
stain  is  to  be  found  on  the  superior  portion  of  the  lateral  external  radial  region,  and  is 
equally  ulcerated  in  the  middle. 

In  the  inferior  third  of  the  palmar  side  of  the  left  forearm  there  is  a stain,  nearly 
round,  little  or  not  at  all  elevated,  and  of  the  diameter  of  three  centimetres.  It  is  a 
darker  red  color  on  the  periphery  and  more  whitish  in  the  centre.  This  stain  existed 
from  the  very  first  day  of  my  observation  of  the  patient. 

The  Inferior  Extremities — The  Right  Leg. — In  the  superior  and  anterior  region  of  the 
right  thigh,  very  near  the  inguinal  fold,  there  is  a large  nodular  excresceuce  of  about 
27  millimetres  diameter,  with  a central  pit,  which  indicates  a preexisting  ulceration 
which  has  spontaneously  healed,  covered  over  with  a very  thin  blood  crust.  This 
excrescence  is  not  pruriginous.  On  the  right  leg  the  affection  is  more  noticeable  on 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


279 


the  antero-external  region,  from  the  calf  to  the  popliteal  space.  A reddish  stain  is  seen 
there,  covered  with  small  nodules  of  various  sizes;  some  being  ulcerated  aud  covered  with 
a yellowish-green  crust.  On  the  internal  lateral  region  there  is  also  a small  elevated 
stain  of  about  3 cent,  diameter.  The  whole  leg  is  also  somewhat  more  voluminous  than 
the  left  one,  and  its  skin  appears  stretched  and  dry,  being  also  very  pruriginous. 

The  Left  Extremity. — The  skin  of  the  left  leg  is  nearly  entirely  normal,  except  some 
small  stains,  a little  elevated  toward  the  margins,  which  are  placed  especially  on  the 
lateral  internal  region.  It  has  also  a more  remarkable  infiltration,  nearly  8 cent,  in 
breadth,  at  the  bend  of  the  knee.  This  is  a little  ulcerated  in  some  points,  but  causes 
very  little  itching. 

June  10th.  Another  examination  of  the  patient  gives  the  following  facts  : — 

In  the  left  scapulo-humeral  region  there  are  no  remarkable  modifications.  The  ulcer- 
ated tubercles  before  observed  remain  there  yet,  just  as  does  the  yellow-greenish  sub- 
stance which  constitutes  their  base  and  which  cannot  be  removed  even  with  the  for- 
ceps. On  the  contrary,  the  sero-lymphatic  exudation  is  here  very  scanty.  The 
different  infiltrated  stains  already  existing  on  the  cervical  region  have  now  acquired  a 
greater  extension  on  the  right  shoulder  also,  without,  however,  papular  or  tubercular 
excrescences  appearing.  These  stains  are  exceedingly  pruriginous,  not  allowing  the 
patient  to  sleep  at  night  more  than  a couple  of  hours. 

From  the  left  axillary  region,  at  the  left  and  posterior  side  of  the  trunk,  to  the  angle  of 
the  scapula,  there  are  many  new  tubercles,  not  yet  ulcerated,  from  5 to  15  millimetres  in 
diameter.  The  same  can  he  said  of  the  anterior  thoracic  region. 

The  only  portion  of  the  trunk  perfectly  sound  is  limited  to  one-half  of  the  dorsal 
region  at  the  right  side  and  a small  extent  on  the  left.  For  the  rest  the  skin  is  here 
more  or  less  taken  up  by  the  tubercular  maculo-papular  infiltration,  which,  while 
growing  in  one  place,  is  absorbed  and  disappears  in  another.  The  existing  ulceration 
corresponding  to  the  umbilical  fossa  is  now  entirely  healed. 

The  whole  right  leg  is  swollen  and  oedematous  ; its  skin  is  reddish,  very  much 
stretched,  so  that  it  cannot  be  taken  up  between  the  fingers.  This  leg  presents  on  the 
superior  portion  of  the  antero-external  region  three  or  four  superficial  ulcerations.  The 
itching  that  it  produces  is  really  insupportable. 

Nothing  remarkable  is  to  be  seen  on  the  left  leg. 


COMPARATIVE  MEASURES  OF  THE  CIRCUMFERENCE  OF  BOTH  LEGS. 


The  right  leg. 

At  the  knee,  flexed,  ....  37  cent. 
Under  the  knee  cap,  . . . . 35  “ 


At  the  calf, 38  “ 

At  the  ankle, 25  “ 


The  left  leg. 

34  cent. 
32  “ 

35  “ 

23  “ 


The  patient  complains  of  a feeling  of  oppression,  especially  after  meals  ; and  more 
so  if  he  takes  heavy  food.  This  oppression  ceases  altogether  when  he  lays  in  bed. 

June  17th.  The  left  scapulo-humeral  region  is  somewhat  better. 

The  tubercles  already  existing  on  the  nape  are  no  longer  ulcerated  and  are  consider- 
ably flattened. 

In  the  right  sub-axillary  region,  where  the  two  lines  meet,  one  of  which  separates  in 
two  the  axillary  fossa,  and  the  other  proceeding  from  the  nipple  falls  perpendicularly 
upon  it,  there  is  a nodule  as  large  as  a hazel  nut,  much  ulcerated  at  several  points. 

The  right  leg  is  getting  better  ; its  redness  is  diminished  very  much,  but  the  itching 
still  persists. 

July  1st.  The  ulcerations  of  the  tubercles  on  the  left  scapulo-humeral  region  are 
improving,  and  the  yellow-greenish  substance  before  mentioned  can  be  now  detached 
from  it. 


280 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


About  eight  cent,  under  the  last  dorsal  vertebra,  at  the  left  side,  there  appear 
two  new  tubercles,  each  as  large  as  a hazel  nut,  distant  from  each  other  nearly  one 
cent.,  and  both  placed  on  a small  portion  of  infiltrated  skin.  Likewise  on  the  region 
of  the  left  gluteus  some  more  small  tubercles  have  appeared,  which  are  placed  on  a red- 
dish infiltration  connected  with  that  of  the  left  lateral  abdominal  and  sacro-lumbar 
regions. 

On  the  right  leg  there  only  remain  some  thin  yellowish  crusts  that  cover  superficial 
ulcerations,  pouring  out  a very  fluid  serous  liquid. 

It  is  worth  noticing  that  for  the  last  two  months  the  inguinal  glands  are  becoming 
considerably  tumefied,  and  now  appear  as  a large  tumor,  the  size  of  a fist.  It  is  very 
hard,  insensible,  and  almost  immovable. 

July  16th.  The  left  scapulo-humeral  region  is  slowly  improving. 

Likewise  in  the  other  regions  it  seems  that  the  alteration  does  not  progress.  But  on 
the  thoracic  and  abdominal  regions  there  are  a large  number  of  small  papular  excres- 
cences, of  the  size  of  a lentil : more  numerous  on  the  forearms  and  back  of  the  hand 
than  on  the  parts  ; and  more  abundant  on  the  thighs  than  on  the  legs.  These  cause  the 
patient  dreadful  itching.  Several  of  them  are  surmounted  on  the  apex  by  a small  blood 
crust.  Among  them,  moreover,  are  to  be  noticed  some  small  vesicles  containing  a serous 
or  sero-purulent  liquid.  Besides,  the  left  inferior  extremity,  especially  the  leg,  is  some- 
what swollen  and  cedematous,  principally  on  the  anterior  region,  where  the  pressure  of 
the  finger  leaves  a sensible  depression. 

August  7th.  The  patient,  for  nearly  a week,  has  been  tormented  by  a fever,  which 
comes  on  daily  on  his  rising  from  bed,  at  about  six  o’clock.  This  fever  goes  down  at 
about  two  o’clock,  p.m.  of  the  day.  He  had  this  same  complaint  last  year  also,  without, 
however,  having  any  chills  beforehand. 

On  the  deltoid  and  external  scapular  region,  on  the  right  side,  the  affection  has  increased. 
Here  we  notice  numerous  hemispherical  prominences,  some  of  which  are  superficially 
ulcerated  and  of  a yellowish-gray  color,  and  exuding  a lemon-yellow  serous  liquid.  One 
of  these  prominences  reaches  the  size  of  a large  almond.  I have  cut  a piece  out  of  this 
tumor,  in  order  to  subject  it  to  microscopic  examination.  Only  on  one  point  of  this  same 
left  scapular  region  the  affection  has  undergone  such  an  involutive  phase  that  a large 
stain  is  to  be  observed  there. 

The  retro-cervical  and  suprascapular  regions  are  getting  to  be  of  a red-orange  color, 
without  exudation. 

The  dorsal  region,  principally  at  the  right  side  and  on  the  median  line,  is  almost 
entirely  round.  On  the  contrary,  the  lumbar  and  sacral  regions  are  becoming  of  a red- 
brownish  color,  and  are  covered  with  numerous  protuberances,  more  or  less  large,  all 
appearing  broken  down  on  the  surface  and  bleeding  at  the  least  touch. 

The  anterior  thoracic  region  and  the  abdominal  region  can  be  said  to  be  entirely  affected 
over  their  whole  surface  ; for  only  a small  portion  of  the  skin  is  here  yet  healthy. 

The  glandular  tumefaction  still  continues  in  the  right  inguino-crural  region,  and 
with  the  same  characters.  In  the  left  inguinal  region,  also,  the  glands  are  smaller,  but 
they  are  less  conglobate  and  movable. 

The  cedematous  tumefaction  of  the  legs  also  goes  on  ; it  extends  a little  upward  to 
the  thighs,  and  downward  to  the  feet.  The  skin  of  the  legs,  however,  appears  to  be 
affected  by  eczema  rubrum.  The  right  leg,  at  the  calf,  measures  41  cent.,  the  left  37. 

The  itching  on  the  whole  cutaneous  surlace  is  indescribable.  The  patient  scratches 
himself  all  over  till  he  bleeds. 

The  patient  got  worse  toward  the  middle  of  August. 

The  fever  became  continuous,  and,  according  to  the  local  medical  reports,  a broncho- 
pulmonary disease  was  added  to  it,  with  profuse  diarrhoea  of  very  pestiferous  character, 


'HNOLAIM  ft  ION  IITM  PHfLA 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


281 


during  which,  as  I was  told,  the  stains  got  gradually  paler  ; their  secretion  ceased, 
tumors  on  the  skin  remaining  only. 

This  patient  died  on  the  17th  of  August,  1885,  preserving  to  the  last  his  mental 
faculties  intact. 

CASE  II. — MYCOSIS  FUNGOIDES  OF  ALIBERT  (PSORIASIS  PRiEGRESSA). 

Diagnosis. — Francis  Rocco,  of  Afragola,  aged  sixty-five  years,  a wool  carder  ; is  mar- 
ried, and  has  at  present  six  children,  all  living  and  in  good  health.  But  about  twenty 
years  ago  he  lost  four  other  children  when  young  ; their  malady  he  cannot  now  exactly 
remember.  Both  his  parents  died  of  old  age,  two  of  his  sisters  of  cholera  morbus,  and 
a brother  of  a chronic  bronchial  catarrh.  One  of  his  sisters  is  living  still  and  enjoys 
good  health. 

He  has  always  been  well,  nor  has  he  suffered  from  any  disease  worth  noticing, 
except  an  affection,  probably  of  a typhoid  character,  at  the  age  of  twenty,  and  scabies, 
which  he  got  fifteen  years  ago. 

His  actual  cutaneous  malady  began  two  years  ago,  without  any  cause  known  to  the 
patient,  unless  it  be  his  affliction  when,  about  five  years  ago,  his  three  nephews  were 
killed  by  a house  falling  upon  them.  His  disease  first  appeared  on  his  back,  under  the 
form  of  efflorescenses  of  various  dimensions,  lightly  pruriginous,  covered  over  with  sil- 
ver-white scales,  to  which  he,  at  the  beginning,  did  not  pay  much  attention,  but  which, 
after  the  lapse  of  two  months,  spread  all  over  the  chest,  and  later  gradually  covered  his 
superior  extremities  and  the  internal  surface  of  his  right  thigh.  Last  year,  in  the 
month  of  February,  he  presented  himself  at  the  dispensary  belonging  to  the  Clinic  of 
this  city,  where  his  disease  was  pronounced  to  be  psoriasis.  Consequently,  he  was  given 
pills  of  chrysophanic  acid.  He  bore  them  well ; so  much  so  that  he  used  to  take  thirty- 
two  of  them  daily,  although  they  each  contained  two  centigrams  of  acid.  He  followed 
this  treatment  without  any  profit  for  fully  five  months  ; for  the  affection  persisted  with 
a surprising  tenacity;  nay,  the  stains  of  the  affected  skin  seemed  every  day  of  more  bril- 
liant red  color.  They  were  considerably  infiltrated  and  slightly  exudating  ; so  that 
they  were  no  longer  seen  covered  with  a mass  of  dry,  lucid  and  silvery  scales,  but 
rather  with  crusts,  more  or  less  elevated  and  of  a whitish-yellow  color.  The  itching 
became  ever  more  intolerable.  The  baths  at  Telese  and  the  arsenical  liquor,  taken  per- 
severingly,  did  not  give  any  satisfactory  results. 

At  this  time  (not  determined  with  precision  by  the  patient)  there  began  to  appear, 
on  various  portions  of  the  diseased  skin,  several  small,  reddish  tumors,  with  a surface 
more  or  less  exudating  ; while  at  other  points  there  came  out  superficial  ulcerations. 

The  affection  has  been  always  accompanied  by  a very  violent  itching. 

Actual  Slate  of  the  Patient. — He  is  an  old  man,  of  normal  bodily  constitution  ; his 
skeleton  is  well  developed,  but  his  muscular  system  not  so  much  so.  Panniculus 
adiposus  is  rather  deficient. 

Examination  of  the  Cutaneous  Surface. — (See  Figs.  3 and  4.)  The  affection  is  spread 
all  over  the  trunk,  from  the  neck  to  the  umbilical  line;  more,  however,  on  the  anterior 
and  lateral  surfaces,  than  on  the  posterior  ones.  Besides  this  it  covers  part  of  the  forearms 
and  the  upper  third  of  the  internal  surface  of  the  right  thigh.  In  all  these  places  there 
are  several  stains  of  various  dimensions  (from  about  2 to  3 j cent,  diameter,  and 
larger  too)  ; some  of  which  are  more  or  less  round,  some  ovoidal  and  others  of  a very 
irregular  form;  all  of  a reddish  color  and  more  or  less  infiltrated,  so  as  to  be  in  some 
places  several  millimetres  elevated  overtthe  surrounding  cutaneous  surface.  Several  of 
these  stains  are  covered  with  a stratum  of  scales  of  a whitish-gray  color,  having  in  some 
points  a silvery  glance.  The  scales  are  clustered  together,  so  as  to  form  a crust  more 
or  less  adherent,  that,  on  being  detached,  leaves  a red  surface,  sometimes  bleeding, 


282 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


behind  ; while  others  are  covered  with  regular  crusts  of  a whitish-gray  tint,  conceal- 
ing superficial  ulcerations  on  a grayish  ground,  and  with  a rather  abundant  sero-puru- 
lent  exudation. 

In  some  places  the  tissue  is  elevated,  forming  real  tumors,  the  largest  of  which  is  to 
be  found  on  the  lower  fourth  of  the  internal  surface  of  the  right  arm.  It  reaches  the 
volume  of  half  a pigeon’s  egg,  having  a red  ulcerated  surface.  Some  smaller  ones  are  to 
be  seen  on  the  internal  surface  of  the  left  arm,  and  on  the  back,  principally  at  the  left 
side.  It  is  necessary  to  observe  that  in  some  places  there  are  some  achromic  maculae, 
instead  of  which  there  were  before  efflorescences  similar  to  those  above  noticed  and 
which  have  disappeared  spontaneously. 

Topographical  Description — The  Trunk.  It  is  affected  by  the  disease  on  the  anterior 
surface,  from  the  insertion  of  the  neck  to  the  horizontal  umbilical  line,  and  on  the 
lateral  surfaces  from  the  axillary  fossa  to  the  aforesaid  line.  On  the  dorsal  portion,  on 
the  contrary,  the  affection  begins  at  a level  with  the  sixth  dorsal  vertebra,  and  goes  on 
to  the  base  of  the  sacrum.  Half  the  skin  on  the  right  side  is  more  extensively  affected 
than  on  the  left  side,  where  the  efflorescences,  although  less  numerous,  are  still  more  or 
less  elevated,  all  appearing  under  the  form  of  small  tumors  of  the  size  of  an  almond, 
and  sometimes  still  larger. 

The  Neck. — Here  only  an  infiltrated  skin  is  to  be  seen,  at  the  base  of  the  right  latero- 
cervical  region.  On  the  cephalic  extremity  nothing  is  to  be  observed. 

The  Inferior  Extremities. — The  part  more  affected  here  is  the  upper  third  of  the 
internal  surface  of  the  right  thigh.  On  the  remaining  portions  some  isolated  reddish 
stains  are  to  be  noticed,  lightly  infiltrated. 

The  Superior  Extremities. — The  arms  are  affected  almost  exclusively  and  nearly 
totally,  from  the  deltoid  region  to  the  elbow.  Here  there  are  two  or  three  small  tumors, 
having  the  characters  above  described,  in  the  upper  fourth  of  the  internal  surface  of  the 
left  arm;  and  likewise  another  tumor,  somewhat  larger  (as  big  as  a small  pigeon’s  egg, 
as  I said  before),  on  the  lower  fourth  of  the  internal  surface  of  the  right  arm.  On  the 
forearms  there  are  only  some  few  stains,  lightly  infiltrated,  especially  at  the  bend  (i.  e. 
on  the  upper  half). 

The  lymphatic  glands  are  slightly  enlarged. 

The  patient  complains  of  a very  tormenting  itching. 

Nothing  worthy  of  notice  is  to  be  remarked  in  the  internal  organs. 

Analysis  of  the  Urine. — March  24th.  C.  G.  700.  P.  S.  1019.  Albumen  and  all 
other  chemico-pathological  principles  are  absent.  The  microscopical  analysis,  too,  did 
not  show  anything  abnormal. 

Weight  of  the  Body. — The  patient  on  his  entering  the  clinic  weighed  56,700  kilos. 

Clinical  Diaky,  from  March  23d  to  June  19th. 

Modifications  of  the  Lesions. — March  24th.  On  account  of  the  violent  itching  the 
patient  takes  daily  one  gram  of  potassium.  Temperature  normal. 

March  27th.  No  change  worthy  of  notice.  Temperature  normal. 

March  31st.  Some  old  ulcerations,  especially  on  the  arms,  seem  to  have  a tendency 
to  spread.  The  substance  too,  which  they  secrete,  is  somewhat  abundant.  The  arms 
are  daily  washed  with  warm  water  (100°).  Temperature  normal. 

April  5th.  The  patient  complains  continually  of  an  insufferable  itching.  The  ulcer- 
ations on  the  arms  do  not  appear  to  have  made  much  progress  ; on  the  contrary,  some 
of  these  begin  to  come  out,  very  superficially,  however,  on  the  chest.  Ointment  of 
borax  is  used.  Temperature  normal. 

April  8th.  The  ulcerations  on  the  anterior  surface  of  the  thorax,  and  above  all  on 
its  upper  portion,  increase,  both  in  surface  and  depth;  their  bottom  is  of  a dirty  grayish 
color  with  a scanty  sero-purulent  secretion.  Continued  uugt.  borax.  Temperature  normal. 


Mlcobj  Puri.*?  01  d e Tav.  IV. 


f'linica  Dc^rmo  Hifilopalica  della  R.Universita  cl  i Napoli 

T.De  Amicris  . 


SINCLAIR  4 SON,  L I TM . PHI  LA 


SECTION  XIV DERMATOLOGY  AND  SYPHILOGRAPIIY. 


283 


April  12th.  Nothing  remarkable  is  noticed.  The  itching  is  always  insupportable. 
Two  and  a half  grains  of  bromide  of  potassium  are  daily  given  to  the  patient.  Tem- 
perature normal. 

April  lGth.  The  ulcerations  still  extend,  while  in  some  points  of  the  trunk,  both 
anteriorly  and  posteriorly,  some  stains,  till  now  but  little  infiltrated,  become  more 
prominent.  The  patient  is  still  treated  with  borax  ointment.  I tried  carefully  to  detach 
some  of  the  less  adherent  crusts  that  cover  the  arms  and  trunk.  Temperature  normal. 

April  19th.  On  the  legs  of  the  patient  is  to  be  noticed  the  appearance  of  some  red- 
dish macula;,  of  various  size,  from  about  fifteen  to  twenty-five  mm.  in  diameter.  Tem- 
perature normal . 

April  1st.  The  mciculse  observed  on  the  legs  have  considerably  increased  in  num- 
ber; some  of  them  reach  the  diameter  of  three  cent.  The  affection  has  the  general 
appearance  of  an  erythema  maculosum.  Temperature  normal. 

April  22d.  A small  tumor  already  existing  on  the  inferior  fourth  of  the  internal 
surface  of  the  right  arm,  is  cut  out  and  the  wound  is  dressed  with  ferric  wadding  and 
iodoform  powder.  Temperature  normal. 

April  24th.  The  ulcerations  above  noticed  on  the  trunk  and  arms  show  no  change. 
No  remarkable  modification  till  now  on  the  affected  portion  of  the  right  thigh.  The 
erythema  on  the  legs  remains  as  before.  The  trunk  and  the  arms  are  dressed  with 
pyrogallic  acid  ointment  21  per  cent.  Temperature  normal. 

April  25th.  Some  erythematous  stains  appear  also  on  the  trunk  and  on  the  scalp, 
especially  on  the  forehead.  Temperature  normal. 

April  27th.  The  erythema  is  very  much  increased  in  those  regions  where  it  appeared 
last.  The  dressing  with  pyrogallic  acid  is  suspended  and  the  use  of  the  borax  ointment 
resumed.  Temperature  normal. 

April  29th.  The  erythema  on  the  legs  enters  an  involutive  phase.  The  stains  are 
already  getting  very  pale.  Temperature  normal. 

May  1st.  It  can  be  said  that  the  erythema  has  disappeared  from  the  legs.  On  the 
trunk  and  on  the  scalp  it  begius  likewise  to  go  away.  Temperature  normal. 

May  3d.  The  itching  still  continues  violent.  It  torments  the  patient  so  much 
as  to  allow  him  to  sleep  only  very  little  at  night.  He  takes  daily  one  grain  of  bromide 
of  potassium  and  one  of  sodium.  Temperature  normal. 

May  5th.  The  wound  resulting  from  the  cutting  away  of  the  knot  on  the  arm, 
before  mentioned,  is  getting  on  well  toward  cicatrization.  It  is  cauterized  with  a weak 
solution  of  nitrate  of  silver.  Temperature  normal . 

May  8th.  Those  stains  that  were  beginning  to  become  more  prominent  on  the 
trunk,  both  anteriorly  and  posteriorly,  have  undergone  gradual  increase,  and  some  of 
them  have  turned  into  regular  small  tumors.  The  dressing  with  borax  is  continued. 
Temperature  normal. 

May  12th.  The  ulcerations  in  some  points  show  a tendency  to  heal;  while  in  some 
others  they  spread.  Temperature  normal. 

May  18th.  Some  erythematous  stains  begin  to  be  observed  on  the  back  of  the  hand 
and  on  the  scalp.  A sulphuric  acid  lemonade  is  given  to  the  patient.  Temperature, 
evening  39.7°  C. 

May  21st.  The  erythema  is  spreading  over  the  forearms.  Temperature,  morning, 
38.5°  C. ; evening,  38.6°  C. 

May  24th.  The  erythema  begins  to  appear  also  on  the  trunk,  especially  on  the 
anterior  region  of  the  thorax.  Temperature,  morning,  38°  C. ; evening,  38.5°  C. 

May  27th.  The  erythema  is  in  its  regressive  period  in  those  points  where  it  first 
appeared.  Temperature,  morning,  37.6°  C. ; evening,  37.5°  C. 

May  29th.  A small  trace  of  it  remains  on  the  anterior  surface  of  the  thorax. 
Temperature  normal. 


284 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


May  31st.  The  wound  existing  on  the  right  arm,  where  the  knot  had  been  cut  out 
is  nearly  altogether  cicatrized.  Temperature  normal. 

The  patient  left  the  clinic  on  the  19th  of  June,  to  return  to  his  native  place,  this 
day  being  the  last  of  the  scholastic  year.  I learned  that  he  died  some  months  later. 

CASE  III. — MYCOSIS  FUNGOIDES  OF  ALIBERT. 

Diagnosis. — Julia  M.,  of  Naples,  aged  thirty-six  years,  is  married,  and  is  the  mother 
of  seven  children,  five  of  whom  are  living  and  healthy,  and  two  dead,  from  teething. 
Her  father  is  still  living,  hut  her  mother  died  in  childbirth.  Two  of  her  three  brothers 
died  in  their  babyhood,  of  measles,  and  the  last  one  ended  his  life  at  twenty,  from  a 
tuberculo-pulmonary  disease. 

This  patient  has  always  been  well,  and  menstruates  regularly.  She  never  miscar- 
ried, hut, brought  forth  always  happily,  nursing  all  her  children.  One  of  these  once 
suffered  a cutaneous  eruption,  the  character  of  which  she  is  not  able  to  specify,  assur- 
ing us,  however,  that  it  was  in  consequence  of  bringing  that  child  in  contact  with  a 
maid  servant  who  was  affected  with  an  eruption  of  the  skin  which  was  thought  to  he 
of  an  infectious  character.  As  for  the  rest,  none  of  her  family  had  had  cutaneous  affec- 
tions nor  other  maladies  worthy  of  notice. 

The  actual  disease  began  toward  the  year  1880,  just  one  year  after  the  above-men- 
tioned eruptions  on  her  child,  and  in  consequence,  also,  of  very  heavy  sorrow.  Its 
first  manifestation  was  an  intense  itching  all  over  the  cutaneous  surface,  which  increased 
toward  evening,  obliging  her  to  scratch  violently,  so  as  to  produce  very  large  excoria- 
tions on  the  skin.  Two  or  three  months  after  this  terrible  itching  she  observed  that  the 
skin  of  her  extremities  had  become  somewhat  brownish  and  dry,  particularly  over  the 
region  of  the  extensors.  Some  time  after  there  appeared  a small  tumor  in  the  middle 
of  the  anterior  region  of  the  right  thigh,  that,  little  by  little,  grew  to  the  size  of  a 
walnut. 

This  tumor  was  indolent,  of  a rosy  color  and  somewhat  hard.  It  disappeared  after 
two  months,  without  ulceration  and  leaving  au  achromic  stain.  After  this  tumor  had 
gone  away,  another  small  one  came  out  on  the  interior  side  of  the  supra-orbital  region, 
at  the  left  side,  which,  on  getting  of  the  size  of  a hazel  nut,  became  ulcerated,  and 
after  some  months  disappeared,  leaving  no  other  traces  except  a superficial  achromic 
cicatrix. 

After  that  there  appeared  on  different  points  of  the  cutaneous  surface  several  new 
tumors  of  various  size,  some  of  which  became  ulcerated,  leaving  superficial  cicatrices, 
sometimes  hyperaemic  and  sometimes  achromic.  Others,  on  the  contrary,  ended  by 
becoming  superficially  squamous,  not  leaving  any  modification  on  the  skin,  while  there 
were  others  that  left  brownish  or  whitish  stains,  with  a coloring  on  the  surrounding 
skin.  These  tumors  were  from  the  size  of  a lentil  to  that  of  a small  orange,  of  a rosy 
or  deep  red  color,  hard  and  indolent. 

Moreover,  some  of  these  tumors  were  isolated  and  some  were  arranged  in  groups,  so 
as  to  form  fungous  accumulations,  more  or  less  large.  After  several  months,  together 
with  the  tumors,  she  observed  that  on  several  points  of  the  cutaneous  surface  there 
appeared  some  stains  of  various  size,  of  a rosy  or  deep  red  color,  invariably  accompa- 
nied by  an  intense  itching  and  a superficial  furfuraceous  desquamation.  These  stains, 
on  disappearing  from  one  place,  appeared  in  another,  leaving  the  skin  sometimes  in  a 
normal  state  and  sometimes  with  an  increase  or  diminution  of  color.  In  some  places 
the  stains  gradually  became  elevated,  forming  fiat  elevations,  infiltrated  and  of  dif- 
ferent size  and  form,  of  a red  or  brown-red  color,  with  a smooth  surface,  from  two  to 
five  centimetres  high  above  the  skin. 

This  successive  appearance  of  tumors,  of  circumscribed  infiltrations,  and  of  stains 
on  the  skin,  followed  without  interruption  till  the  month  of  November,  1884,  without 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPII Y. 


285 


causing  any  inconvenience  to  the  patient.  At  this  time  she  became  aware  of  the  pres- 
ence of  a small  tumor  on  the  nasal  lobe,  of  a fleshy  color,  as  large  as  a pea.  This  grad- 
ually reached  the  size  of  a cherry,  changing  to  a rosy,  fleshy  hue,  and  with  an  infiltration 
involving  the  whole  right  side  of  the  nose  and  a portion  of  the  sub-orbital  region.  On 
the  zygomatic  region,  at  the  same  side,  the  infiltration  assumed  a special  form — that  of 
a semicircle,  with  the  exterior  convexity  reaching  from  the  nasal  pinna  to  nearly  the 
middle  of  the  inferior  eyelid,  forming  a hard,  elevated  margin,  of  a reddish  color. 

It  was  at  this  time  that  the  patient  was  subjected  to  a course  of  hypodermic  injec- 
tions of  one-half  centigramme  of  sublimate,  each  time,  for  twenty  days.  At  first  it 
appeared  that,  in  consequence  of  this  treatment,  the  regression  of  the  infiltrated  spots, 
especially  of  those  on  the  face,  proceeded  more  rapidly.  After  some  time,  however, 
this  regression  remained  stationary,  and  since  the  nutrition  of  the  patient  did  not  receive 
any  great  advantage  from  it,  and,  moreover,  new  tumors  appeared  on  the  skin,  the 
treatment  was  suspended,  and,  instead  of  it,  a restorative  and  tonic  treatment  was 
undertaken,  consisting  of  iodide  of  sodium,  and  afterward  of  arsenical  liquor  and 
decoction  of  quinine. 

During  the  year  1885  was  noticed  the  successive  appearance  of  other  small  tumors 
on  the  left  sub-orhital  region,  at  the  eyelids  and  on  the  chin.  On  the  trunk  and  on  the 
extremities  there  appeared  several  large  and  flat  infiltrations,  some  circumscribed  and 
others  spreading.  Some  tumors  have  undergone  a complete  regressive  phase  without 
any  solution  of  continuity,  while  on  other  points  they  have  become  ulcerated,  and  in 
some  places  they  have  remarkably  increased  their  volume,  as,  for  instance,  in  the  right 
iliac  region,  one  of  them,  that  had  reached  the  size  of  a walnut,  by  absorbing  the  neigh- 
boring tumors,  has  formed  a mass  as  large  as  a fist,  with  cauliflower  surface  and  ulcer- 
ated in  many  places. 

December,  1885.  The  patient  for  nearly  three  months  was  absent  from  Naples, 
residing  in  a provincial  town,  with  her  husband. 

She  returned  at  the  beginning  of  1886,  in  a very  deplorable  state  of  health  and  very 
much  depressed  in  her  nutrition,  and  feverish  besides.  The  inguinal  glands  at  the 
right  side  had  become  considerably  larger  and  in  the  inguinal  folds  there  was  a tume- 
faction as  large  as  an  orange,  very  painful,  both  under  pressure  and  without  it.  The 
skin  over  it  was  hard,  stretched  and  red,  and  with  a sensible  fluctuation  caused  by 
peridermic  suppuration.  After  a large  incision  was  made,  a very  abundant  quantity 
of  purulent  matter  issued  forth,  and  by  pressing  at  the  sides,  a great  deal  of  yellowish 
caseous  matter  came  out.  Some  more  of  this  matter  was  extracted  by  means  of  a 
spoon  introduced  into  the  abscess  cavity. 

By  using  antiseptic  dressing,  by  washing  with  sublimate  and  by  powdering  with 
iodoform,  the  locality  got  better,  the  suppuration  considerably  diminished,  the  fever 
disappeared,  the  patient  again  acquired  her  strength  and  appetite  and  all  her  conditions 
returned  in  their  primitive  state,  only  there  remained,  where  the  tumor  had  existed,  a 
cavity  four  centimetres  deep,  without  showing  any  tendency  to  cicatrize.  The  disease 
in  general  continued  its  progressive  development.  Here  is  a description  of  the  state 
in  which  the  patient  was  in  May,  1886. 

Her  nutrition,  upon  the  whole,  is  bad,  the  mucosae  are  bloodless  and  on  the  skin,  of 
a pale  tint  in  one  place  and  of  a brownish  one  in  another,  are  spread  a number  of 
tumors,  circumscribed  infiltrations,  together  with  stains  of  various  size,  form  and  color. 

Tie  stains  are  of  the  size  of  a lentil  to  that  of  the  palm  of  the  hand;  some  are  round, 
with  sharp  margins,  others  irregular;  some  isolated  and  others  joined  together,  forming 
erythematic  spots,  reticulated,  with  lines  of  sound  skin  in  the  middle.  Their  color  is 
rosy,  brilliant  red,  brown  red;  the  surface  is  smooth  or  lightly  prominent.  On  some  of 
them  Is  observed  a furfuraceous  superficial  desquamation. 

The  tumors  are  of  the  size  of  a pea  to  that  of  a small  orange;  some  are  isolated  and 


286 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


some  ure  ranged  in  groups  forming  fungous  masses  of  varying  extent.  Their  color  is 
rosy  or  brownish-red;  their  surface  smooth,  almost  polished  in  some  cases,  while  in 
others  it  is  lightly  squamous.  Some  of  them  are  ulcerated  with  a broken-up  surface, 
of  a gray  hue  and  giving  out  a sero-purulent  secretion. 

Their  consistency  is  hard  and  their  margins  either  merge  insensibly  into  the 
surrounding  tissues,  or  are  cut  sharply,  as  isolated  tumors,  over  the  cutaneous  surface. 
Iu  order  to  better  determine  the  form  and  position  of  the  alteration,  we  will  here  under- 
take the  examination  of  the  single  regions. 

The  Scalp. — This  is  provided  with  black  and  coarse  hair,  and  only  toward  the  inferior 
extremities  of  the  temporal  region  are  to  be  seen  two  brownish  stains  with  a superficial 
furfuraceous  desquamation,  which  goes  up  as  far  as  the  superior  massateric  regions. 

The  Face. — On  the  forehead,  near  the  internal  extremity  of  the  left  eyebrow,  there  is 
a superficial  achromic  cicatrix  of  two  cent,  diameter.  Two  small  tumors,  of  the  size 
of  a pea,  are  to  be  seen  on  the  superior  eyelids,  tending  to  disappear  without  ulceration. 
Outside  of  the  left  sub-orbital  region,  near  the  external  angle  of  the  eye,  there  is  a small 
tumor,  of  the  size  of  a hazel  nut,  of  a red-brownish  color  and  hard.  The  nose  is  almost 
all  taken  up  by  a tumor,  that  at  the  right  side  goes  as  far  as  the  internal  third  of  the 
sub-orbital  region.  It  is  of  a brown-reddish  color  and  of  a hard,  elastic  consistency, 
with  an  irregular  surface,  in  some  points  superficially  ulcerated.  It  is  elevated  above 
the  skin  some  few  millimetres,  and  only  on  the  lobe  is  1 J cent.  high.  On  the  left  half 
of  the  inferior  lip  and  on  that  of  the  chin  there  is  another  tumor,  as  large  as  an  almond, 
of  a brownish  color,  with  a smooth  and  desquamating  surface. 

The  Neck. — On  tne  anterior  region  of  the  neck,  by  the  jugular  fovea,  there  is  a stain 
of  the  diameter  of  3 j cent,  somewhat  elevated  over  the  cutaneous  surface,  in  the  middle 
of  which  a nodular  infiltration  is  to  be  seen,  as  large  as  a pea.  On  the  lateral  and  pos- 
terior regions  are  several  stains  and  superficial  infiltrations,  of  various  size  and  form,  of 
a rosy  or  brownish  color,  with  superficial  desquamation  of  the  epidermis. 

The  Trunk. — On  the  anterior  and  lateral  regions  of  the  thorax  there  are  large  portions 
of  sound  skin  with  stains  of  different  size,  of  a rosy  or  red-brown  color,  which  at  the 
mammary  region,  approaching  together,  assume  a reticulated  appearance. 

On  the  posterior  regions  too,  the  same  changes  are  to  be  seen;  the  supra-spinal  regions 
are  taken  up  by  a brownish  stain  with  a superficial  pityriasic  desquamation;  the  right 
sub-spinal  region  is  covered  with  rosy  and  reticulated  stains,  and  toward  the  inferior 
angle  of  the  scapula,  there  is  a tumor  of  the  size  of  an  egg,  with  smooth  surface,  of 
pale  rosy  color,  somewhat  hard  and  detachable  from  the  subcutaneous  tissue. 

In  the  middle  of  the  lumbar  region  a large  brownish  stain  is  to  be  seen,  of  triangular 
form,  with  its  apex  upon  the  vertebras,  the  base  on  the  sacral  region  and  the  two  other 
angles  stretching  toward  the  hips. 

On  the  abdomen  the  skin  is  a little  more  brown.  On  the  anterior  region  and  on  a 
portion  of  the  lateral  one  there  are  several  brown  stains  with  sharp  margins,  of  varying 
form  and  size,  and  also  some  few  of  a deep  red  color,  some  flat  and  some  a little 
elevated. 

In  the  middle  of  the  left  iliac  region  there  are  two  tumors  of  the  size  of  a large 
walnut,  two  cent,  from  each  other,  of  a deep  red  color  with  a smooth  and  polished  sur- 
face, and  of  hard,  elastic  consistency.  In  the  proximity  of  these  tumors,  toward  the 
superior  and  exterior  portion,  there  are  three  other  tumors,  a little  smaller,  which  seem 
to  be  in  a remarkable  regressive  state.  On  the  region  of  the  right  hip  there  exists  an 
enormous  fungous  mass,  circular  in  form,  which  anteriorly  is  limited  by  a vertical  liue 
starting  from  the  anterior  and  superior  spina  iliaca  and  going  to  the  last  rib;  and  poste- 
riorly from  another  vertical  line  parallel  to  the  first,  seven  cent,  distant  from  the  ver- 
tebral column ; below  it  connects  with  the  crista  iliaca,  and  above  with  the  last  rib.  The 
circumference  of  this  fungous  mass  is  52  cent.,  its  vertical  diameter  15  cent,  and  the 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPIIY. 


2S7 


horizontal  18 cent.  The  centre  is  elevated  some  three  cent,  and  the  borders,  at  some  points, 
one  centimetre,  and  at  others  still  less.  The  surface  is  rough  and  full  of  sinuosities, 
with  prominences  and  depressions  very  much  resembling  the  superior  surface  of  the 
cerebral  hemispheres.  It  is  superficially  ulcerated  in  some  places,  while  in  others  the 
ulcerations  are  deep  and  covered  over  with  a hard  and  grayish  eschar,  similar  to  that 
which  is  formed  after  the  application  of  chloride  of  zinc.  Large  pieces  of  it,  one  cent, 
thick,  can  be  detached  from  it  with  the  forceps.  The  whole  fungous  mass  has  a hard 
consistency;  it  cause  no  pains  to  the  patient,  and  from  the  ulcerated  surface  issues  an 
abundant  sero-purulent  secretion. 

The  Superior  Extremities. — The  skin  on  the  exterior  surface  of  the  right  limb  is  of  a 
brown  color,  with  small  achromatic  stains.  The  skin  of  the  flexor  surface,  on  the  con- 
trary, is  covered  with  rosy  or  brown-red  stains  of  various  sizes.  On  the  elbow  there 
is  an  infiltration  of  31  cent,  diameter,  with  ulcerated  surface.  On  the  left  superior 
extremity,  too,  the  skin  presents  the  same  modifications  as  on  the  right  one.  On  the 
region  of  the  deltoid  there  are  several  rosy,  erythematous  stains;  likewise  on  the  region 
of  the  extensors  some  stains  are  noticed,  somewhat  browner.  On  the  superior  fourth  of 
the  arm,  in  the  neighborhood  of  the  bend  of  the  elbow,  there  is  a limited  infiltration 
of  the  diameter  of  about  3-t  cent.,  elevated  two  and  three  centimetres  above  the  skin; 
an  achromic  stain  of  the  same  size  and  form  is  to  be  found  in  correspondence  with  the 
epitrochlea.  On  the  palm  and  on  the  back  of  the  hands  no  alteration  at  all  is  to  be 
observed. 

The  Inferior  Extremities. — On  the  inferior  extremities,  too,  the  skin  is  brown  in  the 
region  of  the  extensors  and  somewhat  dry  and  rough.  On  the  inferior  fourth  of  the 
anterior  region  of  the  left  thigh  there  is  a tumor  as  large  as  an  egg,  as  hard  and  as  red 
. as  the  others.  In  the  right  popliteal  space  another  tumor  is  observed,  of  the  size  of  a 
small  orange,  which  is  ulcerated,  with  a scanty  secretion  and  showing  a tendency  to 
heal.  Both  on  the  thighs  and  on  the  legs  there  are  stains  spread  all  over,  of  various 
size  and  of  a rosy  or  red-brown  color,  with  superficial  desquamation.  On  the  sole  of 
the  foot  there  is  no  alteration. 

The  glands  of  the  neck  and  of  the  armpit  are  little  enlarged.  Those  of  the  left 
inguinal  region  are  as  large  as  an  almond;  in  the  right  inguinal  region  the  glands  are 
very  much  swollen  both  in  the  inguinal  and  in  the  crural  portion.  Iu  the  latter  there 
is  a fistulous  opening,  from  which  issues  forth  an  abundant  sero-purulent  secretion. 
Its  margins  are  thick  and  the  character  of  the  infiltration  has  the  identical  white-gray- 
ish appearance  of  the  tumors  in  an  ulcerative  period.  This  infiltration  goes  deep  in  the 
iliac  fossa  so  that  its  posterior  limits  cannot  be  reached.  This  mass  on  the  anterior 
part,  taken  from  one  side  to  the  other  of  the  fistulous  opening,  has  the  volume  of  a 
fist. 

In  the  oral  cavity  there  is  nothing  abnormal ; likewise  the  organs  contained  in  the 
thoracic  cavity  do  not  present  any  alteration. 

The  Subjective  Facts. — The  patient  suffers  great  itching,  particularly  in  the  evening; 
she  feels  no  pain,  but  only  complains  of  a general  indisposition  and  debility.  Her  tac- 
tile as  well  as  her  thermal  and  dolorific  sensibility  are  in  a perfect  state  in  all  points  of 
the  skin,  even  on  the  single  infiltrations  and  tumors. 

The  patient  undergoes  a tonic  and  roborant  treatment  (quinine,  iron,  arsenical 
liquor). 

For  the  local  modifications  in  the  ulcerated  parts  she  washes  with  sublimate,  powders 
with  the  same  and  dresses  with  ferric  wadding.  On  some  small  tumors  has  been  dried, 
without  success,  the  plaster-mull  prepared  with  clirysoplianic  acid  and  ichthyolate  of 
sodium. 

In  the  month  of  August  I lost  sight  of  this  patient,  for  she  came  to  the  persuasion 


288 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


that  only  from  homoeopathic  treatment  could  she  hope  to  recover;  which,  to  my  regret, 

I could  not  guarantee  to  her. 

She  died  on  the  13th  of  February,  1887. 

CASE  IV.  — MYCOSIS  FUNGOIDES  CIRCUMSCRIBED. 

Diagnosis. — Joan  Della  Sala,  of  Naples,  aged  thirty-three  years;  is  married;  she  has 
children,  three  of  which  are  living  and  three  died  of  ordinary  diseases. 

She  does  Dot  remember  having  suffered,  during  her  life,  from  any  disease  except  fre- 
quent attacks  of  erysipelas  of  the  face.  She  was  in  good  health  till  July,  1886,  when 
she  began  to  observe  near  the  region  of  the  right  hip,  corresponding  to  the  margin  of 
the  crista,  iliaca,  a reddish  stain  of  about  21  cent,  diameter,  very  pruriginous  and  secret- 
ing a serous  fluid.  Little  by  little,  however,  this  stain  has  become  infiltrated,  and 
from  that  time  it  has  given  no  signs  of  regression,  but,  on  the  contrary,  it  has  slowly 
extended  its  limits. 

In  the  month  of  April,  1887,  the  patient  came  to  me,  and  here  is  what  I could 
observe  on  her:  She  is  a woman  of  regular  skeletal  conformation;  in  general  well  nour- 
ished; the  color  of  her  skin  is  pale  rose.  The  objective  examination  of  the  skin  does 
not  present  anything  worthy  of  notice  except  in  the  region  of  the  right  hip,  as  above 
noted.  Here  there  is  an  oblong  stain,  horizontally  placed,  of  about  4 by  3 cent.  It  is  of  a 
reddish  color;  the  skin  appears  infiltrated,  and  to  the  touch  gives  a soft  elastic  resist- 
ance. Its  margins  are  sharp,  but  gradually  descend  to  the  level  of  the  skin,  so  that  it 
assumes  an  ellipsoid  form,  having  in  the  middle  the  greatest  thickness  of  infiltration. 

It  is  very  pruriginous,  and  presents  on  the  surface  a superficial  epidermoid  erosion,  from 
which  issues  a serous  secretion. 

Treatment. — It  is  dressed  with  glycerolate  of  iodoform,  and  after  some  days  with  - 
plaster-mull  prepared  with  chrysophanic  acid. 

No  advantages  were  obtained;  nay,  the  limits  of  the  lesion  gradually  extended 
themselves,  so  that  on  May  23d,  1887,  it  presented  a surface  71  by  41  centimetres, 
always  keeping  the  ellipsoid  form.  The  surface  is  still  reddish,  but  it  is  less  secreting, 
although  still  pruriginous. 

May  26th,  1887.  With  the  consent  of  the  patient,  I have  practiced  an  excision  near 
the  extreme  limit  or  external  side  of  the  lesion,  so  as  to  take  up  the  whole  thickness  of 
it  and  where  the  surface  does  not  present  any  erosion. 

The  glands  of  the  right  inguinal  region  are  now  very  much  swollen  and  ache  under 
pressure.  One  of  the  glands  reaches  the  volume  of  a large  walnut. 

June  20th.  The  state  of  the  lesion  is  the  same.  After  rendering  the  surface  aseptic, 

I made  two  cuts  at  right  angles  to  each  other  and  on  the  point  of  intersection,  with  a 
sterilized  pipette.  I took  some  blood,  putting  a part  of  it  in  a tube  with  gelatine,  and 
the  other  portion  in  another  tube  with  broth. 

July  15th.  The  cultures  have  not  given  any  result;  no  germs  have  developed. 

REMARKS. 

The  four  clinical  cases  above  described  clearly  show  that  the  diagnosis  which  I have 
made  of  them  corresponds  to  the  characters  which  this  lesion  in  general  presents,  and 
therefore  it  is,  perhaps,  not  out  of  place  to  enter  upon  a diagnostic  discussion  of  the 
subject. 

The  first  case  brings  to  our  minds  the  typical  forms  of  such  an  affection  in  all  its 
various  stages— maculous,  congestive,  lichenoid,  neoplastic,  ulcerative,  fungoid.  (See 
Figs.  1 and  2. ) 

The  second  case  is  preceded  by  a psoriasis,  and  while  this  was  in  a regressive  state 
the  mycosis  fungoides  has  appeared,  both  on  the  remaining  anaemic  stains  of  the  psoriasis 
and  on  other  points.  A similar  case  has  been  also  observed  by  Simon. 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


289 


The  third  case  belongs  to  the  variety  that  has  been  already  studied  by  Bazin,  in 
which  neither  a congestive-eczematic  period  is  noticed  nor  a lichenoid-premonitory 
one;  but  the  neoplastic-fungoid  period  is  directly  established  from  the  very  beginning. 
Consequently,  this  case  presented  in  its  beginning  a picture  not  very  dissimilar  from 
that  of  the  tubercular  form  of  syphilis,  or  of  leprosy,  and  that  till  the  tumors 
reached  the  extraordinary  volume  and  the  configuration  (massa  encephalica)  which  is 
characteristic  of  this  malady.  It  is  also  worthy  of  notice  in  this  case  that  during  the 
ulcerative  period  eschars  formed,  as  hard  and  irritant  as  those  which  are  obtained  from 
cauterization  with  chloride  of  zinc..  Here  it  is  to  be  observed  that  the  hypodermic 
mercurial  treatment  and  the  local  application  of  a solution  of  sublimate  had  no  result 
whatever.  The  complete  evolution  and  the  lethal  issue  of  the  disease  took  place,  in 
the  first  three  cases,  during  the  space  of  from  two  to  three  years. 

The  fourth  case,  on  account  of  the  circumscribed  form  of  the  affection,  is  yet  an 
object  of  study  and  observation  to  me.  In  no  one  of  these  four  cases  did  I meet  with 
leucaemia,  although  in  the  first  and  third  cases  the  glands  were  remarkably  implicated. 

The  anatomo-pathologic  nature  of  this  alteration  is  at  present  a subject  of  debate 
among  the  dermatologists.  As  long  as  the  greatest  importance  was  given  to  the  form 
and  disposition  of  the  histological  elements  which  constitute  the  structure  of  the  neo- 
plasm, the  structure  of  the  neoplasm  might  well  be  compared  to  that  of  the  lympho- 
demia  ganglionaris  (Ranvier),  such  a judgmeut  being  based  principally  upon  the 
presence  of  nuclear  lymphoid  elements  in  the  middle  of  a connective  reticulum.  This 
is  the  reason  for  which,  in  my  observations,  published  in  1882,  I thought  proper  to 
adopt  the  nomenclature  “ Dermo-lympho-adenoma-fungoides.”  Further  researches  and 
the  progress  of  science,  however,  have  rightly  sanctioned  the  view  that  whatever  be  the 
importance  of  the  modifications  that  the  tissues  undergo  in  their  structure,  they  cannot, 
for  themselves  alone,  serve  to  determine  the  nature  of  a malady,  and  that  to  the  mor- 
phologic product  often  there  cannot  be  ascribed  an  absolute  value  if,  at  the  same  time, 
it  be  not  considered  in  relation  to  the  cause,  the  localization  and  the  symptoms  of  the 
malady.  Therefore  it  has  been  considered  that  the  presence  of  the  reticulated  tissue 
on  the  tumor  of  the  mycosis  is  not  sufficient  to  establish  its  absolute  identity  with  the 
lympho-adeno- ganglionaris.  Anatomically  considered,  the  mycosis  fungoides  presents 
one  of  the  forms  of  a granuloma  which  has  a great  analogy  with  other  granuloma  of 
different  origin,  but  of  similar  appearance,  just  because  their  anatomical  substratum  is 
the  same,  aud  the  elements,  in  consequence  of  the  stimulus,  cannot  undergo  a reaction 
or  alteration,  except  according  to  some  determined  way,  while  the  essential  difference 
between  these  affections  follows  from  their  different  origin,  so  that  the  nature  of  the 
cause  will  in  future  point  out  the  evolution  and  the  phases  of  the  malady  that  consti- 
tute the  particular  physiognomy  and  the  clinical  type  of  the  lesion  (granuloma  leprosum, 
luposum  syphiliticum  and  mycosis  fungoides). 

At  the  point  at  which  the  scientific  knowledge  is  at  present  the  question  of  the 
intrinsic  quality  of  the  morbific  alterations  seems  to  be  of  greater  importance  than  the 
form.  Not  infrequently  some  affections,  the  morphologic  products  of  which  do  not 
give  any  anatomical  difference  worthy  of  notice,  are  different  relatively  to  their  origin 
and  present  a diverse  clinical  type  and  evolution.  The  scientific  researches,  therefore,  of 
possible  etiological  moments  of  a given  alteration  is,  at  the  present  time,  one  of  the 
most  important  questions,  especially  from  the  point  of  view  of  the  existence  of  special 
pathogenic  parasites,  which  could  indicate  their  different  quality.  To  this  purpose  it 
has  been  inquired  if  in  the  mycosis  fungoides  there  could  be  found  a special  parasite. 
Auspitz  and  Rindfleisch  have  answered  affirmatively.  The  former,  together  with 
Hochsinger,  by  coloring  the  preparations  with  lithio-earmine  and  malachite  green,  and 
treating  them  afterward  with  the  method  of  Gramm,  has  found  a parasite  in  the  granulo- 
matous tissue,  in  the  squamaj,  in  the  eczematic  and  lichenoid  eruptions,  and  in  the 
Vol.  IV— 19 


290 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


roots  of  the  hair.  Dr.  Scbiff  has  undertaken,  with  success,  the  culture  of  the  micro- 
coccus. Rindfleisch,  at  the  same  time  as  Auspitz,  announced  that  he  had  observed  a 
particular  parasite  in  mycosis  fungoides.  He  regards  it  as  a strepto-cocoon  ; and,  differ- 
ing from  Auspitz,  who  describes  it  in  the  crevices  of  the  tissues,  he  is  of  opinion  that  it 
occupies  exclusively  the  vessels,  and  not  the  tissue,  and  that  the  colonies  form  agglom- 
erations obliterating  the  opening  of  the  vessels.  He  has  also  employed  the  method  of 
Gramm  for  colorization. 

Prof.  Kdbner  in  his  late  communication  to  the  Section  of  Dermatology  andSyphilo- 
graphy,  in  the  59th  Congress  of  the  German  Physicians  and  Naturalists,  in  Berlin,  says, 
that  by  using  all  the  known  methods  of  coloring  the  parasites,  he  has  not  been  able  to 
obtain  from  them  any  result,  and  thinks,  therefore,  the  parasites  found  by  Auspitz  and 
Rindfleisch  are  accidental. 

Neisser  admits  the  presence  of  parasites,  but  he  is  of  opinion  that  their  interpreta- 
tion is  premature,  for  they  are  to  be  found  only  in  the  ulcerated  nodosities,  while  they 
are  wanting  in  those  covered  with  epithelial  strata  ; a fact  which  might  indicate  the 
parasites  to  be  of  extraneous  origin  and  not  produced  by  the  disease. 

Of  all  the  four  cases  here  described,  I have  been  able  to  make  a histological  aDd 
bacterioscopic  analysis.  Simple  microscopic  observation  has  proved  to  me,  in  all  the  four 
cases,  the  identical  granulomatous  aspect  regarding  the  morphology,  that  is  to  say,  that 
on  the  skin  are  to  he  seen  round  nuclear  elements,  recalling  to  mind  the  embryo  tissues, 
all  homogeneous,  more  or  less  near  to  each  other,  and  which  little  by  little  become 
extended  into  the  hypoderma.  The  mucous  body  of  Malpighi  in  the  sections  is  to  be 
seen  perfectly  preserved,  being  at  some  points  hypertrophic  with  infiltration  going 
deeply  into  the  tissue. 

The  bacteriologic  analysis  made  at  first  according  to  the  method  of  Weigert,  etc., 
has  given  constantly  negative  results,  although  it  has  been  often  repeated,  using  all 
possible  precautions.  The  renewed  experiments,  however,  for  a long  time  unsuccessful, 
did  not  shake  my  faith,  nor  diminish  my  hope  of  being  able,  by  perseverance,  to  reach 
finally  the  object  in  view,  and  my  coadjutor,  Dr.  Melle,  by  changing  the  method  of 
colorization  in  a thousand  different  ways,  came  at  last  to  prepare  a liquid  which  has 
completely  answered  in  every  case  for  the  bacterial  analysis  of  the  mycosis  fungoides. 
His  composition  is  the  following  : — 

Gentian  violet,  cm.  c.  3. 

Oil  of  anilin,  cm.  c.  3. 

Absolute  alcohol  at  99°,  grm.  15. 

Distilled  water,  grm.  80. 

Method  of  Using  it. — Let  the  prepared  pieces  lie  from  two  to  twenty-four  hours  in 
the  solution.  Put  them  afterward  in  absolute  alcohol  till  this  does  not  take  up  any 
more  violet  color  (which  happens  in  twenty-four  hours).  After  having  washed  them  in 
clove  oil  or  in  that  of  bergamot,  they  are  put  in  xylolic  balsam.* 

Having  analyzed  the  pieces  with  this  method,  I have  been  able  to  prove  the  presence 
of  parasites,  that  is  to  say,  of  micrococci,  colonies  of  which  exist  in  the  papillary  body 
of  the  skin,  and  deeper  also  in  the  hypoderma,  i.  e.,  in  the  interstices  of  the  newly 
formed  elements.  I have  found  them,  moreover,  in  the  rete  Malpighi.  (See  Fig.  5.) 

With  a stronger  magnifying  power  is  to  be  seen  that  the  colonies  of  parasites  assume 
different  forms,  some  round  and  some  oblong,  some  cylindrical  and  some  in  larger  accu- 


* In  order  to  obtain  a good  solution  of  violet  of  gentinna,  it  is  advisable  to  use  the  follow- 
ing method  : Put  first  in  a bottle  the  violet  of  gentiana,  finely  pulverized  ; pour  therein  ani- 
line oil  and  afterward  absolute  alcohol ; shako  well  the  bottle  for  several  minutes;  add  distilled 
water  and  continue  to  agitato  the  whole  for  twenty  or  thirty  minutes;  filter  and  the  coloring 
liquid  is  ready  for  use. 


I 


SECTION  XIV — DERMATOLOGY  AND  SYPHILOGRAPHY. 


291 


mulations.  (See  Fig.  G. ) The  greatest  quantity  of  them  is  to  be  found  in  the  papillary 
body  and  in  the  connective  subcutaneous  tissue,  in  the  form  of  oblong  ovoidal  conglom- 
erations, which  are  afterward  seen  to  emigrate  also  in  the  inferior  part  of  the  rete 
Malpighi. 

I have  not  been  able  to  observe  in  the  blood  vessels  any  parasitic  infiltration.  The 
possibility  cannot,  however,  be  excluded,  that  they  may  be  found  in  the  lymphatic 
vessels,  because  the  agglomerations,  -which  are  often  to  be  seen,  of  a cylindric  and  flex- 
ible form,  remind  one  of  a vessel,  although  the  existence  of  a wall  can  only  with  diffi- 
culty be  proven. 

The  elements  of  all  the  four  preparations  which  I had  cut  out  from  the  patients 
whose  cases  have  been  here  described  react  alike  to  this  method  of  colorization,  and 
especially  that  of  the  third  case,  in  which  the  tumors  appeared  not  to  have  been  pre- 
ceded by  the  eczematic  and  lichenoid  period. 

The  aforesaid  method  being  applied  to  other  preparations  of  other  affections  (rhino- 
scleroma,  lupus,  syphilis,  etc).,  did  not  give  any  result. 

I have,  moreover,  used  this  mode  of  colorization  to  a multiple  idiopathic  sarcoma, 
not  pigmented,  which  I had  the  occasion  of  observing  some  few  years  ago,  and  of  which 
I kept  the  pieces  cut  out  and  a drawing  showing  its  alteration.  The  result  has  been 
perfectly  negative. 

After  having  obtained  these  proofs,  I proposed  to  myself  to  see  if  I could  obtain  the 
same  result  by  subjecting  to  the  described  method  of  colorization  some  preparations 
that  I had  kept  belonging  to  the  first  of  the  two  cases  which  I reported  in  1882 
(La  Scienza),  and  I have  found  out  the  same  elements,  just  as  in  the  four  cases  in 
question. 

We  may,  therefore,  conclude,  from  all  this,  that  the  presence  of  parasites,  in  my 
observations,  is  not  merely  accidental,  but  a constant  fact,  and  belonging  exclusively  to 
the  nature  of  the  affection,  and  that  these  parasites  exist  also  in  places  where  the  epi- 
thelia  is  perfectly  preserved. 

The  culture,  dried  writh  the  blood  taken  from  the  tumors  of  the  third  case,  gave  colo.- 
nies  of  micrococci  and  streptococci,  but  for  the  fourth  case  the  experiments  had  no 
result. 

It  follows  from  what  has  been  said:  1st,  that  mycosis  fungoides  is  a morbid  entity 
by  itself,  different  from  the  general  idiopathic  cutaneous  sarcomata,  not  pigmented.  2d, 
that  the  said  mycosis  fungoides  consists  of  a specific  cutaneous  infiltration,  infective 
but  not  contagious;  similar  to  that  of  tubercular  disease,  of  leprosy  and  of  syphilis.  3d, 
that  in  this  infiltration  the  presence  of  parasites  is  constant  and  not  accidental,  and  that 
it  can  be  observed  with  a special  method  of  staining.  4th,  that  by  means  of  the  afore- 
said method  of  staining,  we  now  possess  a diagnostic  criterion  which  enables  us  to  dis- 
cover, in  doubtful  cases,  the  nature  of  the  granuloma  belonging  to  the  mycosis  fun- 
goides; just  as  it  is  with  the  bacillus  of  Koch  in  tubercular  disease,  and  that  of  Hausen 
in  leprosy.  5th,  that  it  belongs  to  the  future  discoveries  of  science  to  state  better  the 
pathogenic  value  of  this  parasite  in  order  to  affirm  with  absolute  certainty  the  parasitic 
nature  of  the  disease. 

In  conclusion,  I may  be  allowed  some  few  words  about  the  nomenclature  to  be  pre- 
ferred for  this  neoplastic  form  of  disease.  In  my  first  communication  (1882)  I adopted 
in  preference  the  denomination  of  dermo-lympho-adenoma  fungoides  because  by  it  was 
better  expressed  its  anatomo-pathologic  meaning  according  to  the  views  of  that  time, 
and  also  because  by  it  a possible  confusion  was  avoided  which  the  word  mycosis  might 
cause.  On  account,  however,  of  the  observations  made  and  of  the  constant  presence  of 
parasites,  and  considering  that  the  existence  of  a reticulum  containing  lymphatic  ele- 
ments does  not  constitute  its  special  characteristic,  and  that  the  granulomatous  form  does 
not  represent  the  absence  of  the  malady,  I willingly  subscribe  to  the  arguments  of  Bes- 


292 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


nier*,  accepted  also  by  Kbbner,  and  bold  that  it  is  more  advisable  to  keep  the  old 
nomenclature  given  to  it  by  Alibert,  of  mycosis  fungoides,  as  a more  comprehensive 
denomination,  as  being  less  exposed  to  the  fluctuation  of  science,  for,  compromising 
nothing,  it  leaves  all  freedom  to  the  future  discoveries  necessary  to  enlighten  the  obscure 
points  which  yet  exist  in  the  pathogenesis  of  this  interesting  malady. 


EXPLANATION  OF  THE  FIFTH  PLATE. 

Fio.  5. — A preparation  (Zeiss.  Oc.  3,  Ob.  CC.,  elevation  of  the  tube  16  cent.)  showing  the  Beat  and  dis- 
position of  the  parasitic  elements,  both  in  the  cutis  and  in  the  papillae,  as  well  as  in  the  Malpighian 
body. 

Fig.  6 — A preparation  (Zeiss.  Oc.  3,  ininom.  ,'j,  elevation  of  the  tube,  15.5)  representing  a deeper 
point  of  the  cutis  and  of  the  underlying  tissue,  which  shows  the  various  forms  of  agglomeration  of  the 
micro-cocoon.  Some  of  these  are  oblong  and  flexuous,  some  circular  ; some  spread  all  over  like  points, 
and  others  as  if  surrounded  by  a granulous  element,  which  in  the  middle  appears  more  transparent.. 


Upon  motion  of  Dr.  Unna  a vote  of  thanks  to  Dr.  Robinson,  for  his  zeal  and 
success  in  behalf  of  the  Section,  was  passed,  and  the  Section  closed. 


* Besnier.  Annalea  de  Dermatologie  et  Syphiligraphie,  1884,  p.  39. 


DR,  CHAS,  W.  HITCHCOCK. 

FROM  WE  LIBRARY  OF 

DR.  H.O.  HITCHCOCK. 

SECTION  XV-PUBLIC  AND  INTERNATIONAL  HYGIENE. 


OFFICERS. 

President:  JOSEPH  JONES,  A.  M.,  M.  D.,  New  Orleans,  La. 


VICE-PRESIDENTS. 


A.  Nelson  Bell,  m.d.,  New  York,  N.  Y. 

Georoe  Buchanan,  m.d.,  b.a.,  f.r.s.,  London, 
England. 

Surgeon  C.  C.  Byrne,  m.d.,  Soldier’s  Home, 
Washington,  D.  C. 

Professor  Corrado  Tommasi  Crudeli,  m.d., 
Rome,  Italy. 

Richard  H.  Day.  m.d.,  Baton  Rouge,  La. 

J.  W.  Dupre,  m.d.,  Baton  Rouge,  La. 

R.  K.  Fox,  m.d  , Jesuit's  Bend,  La. 

Domingos  Freire,  m.d.,  Rio  de  Janeiro,  Brazil. 

J.  A.  S.  Grant  (Bey),  m.d.,  ll.d.,  etc.,  Egypt. 
Professor  Robert  Koch,  m.d.,  Berlin,  Germany. 
John  B.  Lindsley,  m.d.,  Nashville,  Tenn. 

Professor  Carmona  Y Valle, 


A.  Magnin,  m.d.,  Lyons,  France. 

E D.  Mapother,  m.d.,  Dublin,  Ireland. 

J.  N.  McCormack,  m.d.,  Bowling  Green,  Ky. 

J.  F.  Y.  Paine,  m.d.,  Galveston,  Texas. 

M.  Louis  Pasteur,  Member  of  Academy  of 
Science,  Paris,  France. 

P.  Byrnberg  Porter,  m.d  , New  York  City,  N.  Y. 
R.  Harvey  Reed,  m.d.,  Mansfield,  Ohio. 
Benjamin  Ward  Richardson, m.d., f.r.s.,  Lon- 
don, England. 

John  Simon,  m.d.,  f.r.s.,  Loudon,  England. 

A.  K.  Smith,  m.d.,U.  S.  Army,  West  Point,  N.  Y. 
J.  L.  W.  Thudichum,  m.d.,  f.r.s.,  London,  Eng- 
land. 

D.,  City  of  Mexico,  Mexico. 


SECRETARIES. 


J.  J.  Castellanos,  m.d.,  New  Orleans,  La. 
Felix  Formento,  m.d.,  New  Orleans,  La. 

Y.  R.  Le  Monnier,  m.d.,  New  Orleans,  La. 

Wm.  R.  Steinmetz,  m.d.,  Assistant  Surgeon, 
U.  S.  Army. 


B.  D.  Taylor,  m.d.,  U.  S.  Army,  Columbus 
Barracks,  Columbus,  Ohio. 

Walter  Wyman,  m.d.,  U.  S.  Marine  Hospital 
Service,  New  York,  N.  Y. 


COUNCIL. 


T.  S.  Antisell,  m.d.,  Washington,  D.  C. 

Le  Baron  Botsford,  m.d.,  St.  Johns,  N.  B. 
Henry  Carpenter,  m.d.,  Lancaster,  Pa. 
Oscar  DeWolf,  m.d.,  Chicago,  111. 

Wm.  Duncan,  m.d.,  Savannah,  Ga. 
Landon  B.  Edwards,  m.d  , Richmond,  Va. 
James  Finney,  m.d.,  New  Orleans,  La. 
Wiley  K.  Fort,  m.d.,  New  Orleans,  La. 

E.  L.  B.  Godfrey,  m.d.,  Camden,  N.  J. 

D.  W.  Hand,  m.d.,  St.  Paul,  Minn. 

Chas.  H.  Hewitt,  m.d.,  Red  Wing,  Minn. 
Thomas  Hebert,  m.d.,  New  Iberia,  La. 
Stanhope  Jones,  m.d.,  New  Orleans,  La. 
Benjamin  Lee,  m.d.,  Philadelphia,  Pa. 


A.  W.  Leighton,  m.d.,  New  Haven,  Conn. 
William  R.  Mandeville,  m.d.,  New  Orleans,  La. 
U.  R.  Milner,  m.d.,  New  Orleans,  La. 

H.  L.  Orme,  m.d.,  Los  Angeles,  Cal. 

W.  L.  Schenck,  m.d.,  Osage  City,  Kansas. 

R.  M.  Swearingen,  m.d.,  Austin,  Texas. 

C.  M.  Smith,  m.d.,  Franklin,  La. 

M.  K.  Taylor,  m.d.,  U.  S.  Army,  San  Antonio, 
Texas. 

G.  Troup  Maxwell,  M D.,  Ocala,  Fla. 

C.  B.  Thornton,  m.d.,  Memphis,  Tenn. 

William  W.  Welch,  m.d.,  Philadelphia,  Pa. 

C.  P.  Wilkinson,  M D.,  New  Orleans,  La. 

C.  D.  Owen,  m.d.,  Eola,  La. 


293 


294 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


FIRST  DAY. 


[note  by  the  president  op  the  section.] 

In  the  reporting  of  the  discussions  on  the  following  papers,  in  the  record  of  the  minutes,  and  in 
the  translation  of  French,  Italian  and  German  papers  and  remarks,  most  valuable  assistance  was  ren- 
dered by  the  following  gentlemen  : — 

American,  Walter  Wyman,  m.  d.,  U.  s.,  Marine  Hospital  Service,  New  York,  N.  Y.;  B.  D.  Taylor, 
m.  D.,  u.  s.  A.,  Columbus  Barracks,  Columbus,  Ohio. 

French,  Y.  R.  Le  Monnier,  m.  d.,  New  Orleans,  La. 

Italian  and  German,  Felix  Formento,  m.  d.,  New  Orleans,  La. 

German,  Wm.  R.  Steinmetz,  m.  d.,  Assistant  Surgeon,  u.  s.  a. 


The  Section  on  Public  and  International  Hygiene  met  at  the  Cornwell  Building, 
Pennsylvania  Avenue,  Monday,  September  5th,  at  3 P.  M.,  and  was  called  to  order 
by  the  President,  who  delivered  the  following  address  : — 

PUBLIC  AND  INTERNATIONAL  HYGIENE. 

HYGIENE  PUBLIQUE  ET  INTERNATIONALE. 

UBER  OFFENTLICHE  UND  INTERNATIONALE  HYGIENE. 

ADDRESS  BY  JOSEPH  JONES,  M.  D. , 

Of  New  Orleans,  Louisiana. 

Gentlemen — As  representatives  of  the  science  and  humanity  of  the  nineteenth 
century,  you  have  assembled,  from  various  civilized  nations,  in  the  capital  of  the 
North  American  Republic,  to  deliberate  upon  subjects  of  paramount  importance  to 
the  welfare  of  mankind. 

Your  deliberations  will  be  studied  with  interest;  and  your  decisions  concerning 
the  great  issues  and  problems  presented  by  the  science  and  art  of  Public  and  Inter- 
national Hygiene  should  be  regarded  as  expressing  the  practical  results  and  precepts 
of  scientific  investigation,  profound  thought  and  wide  generalization. 

To  those  noble  and  self-sacrificing  men  who  have  temporarily  laid  aside  the  daily 
discharge  of  the  important  duties  assigned  them  by  their  countrymen,  and  crossed 
the  stormy  Atlantic  to  engage  in  deliberations  relating  to  the  cause  and  prevention  of 
disease  and  the  amelioration  of  human  suffering,  we  extend  a hearty  welcome. 

It  is  not  our  province  to  recount  the  might  and  power  of  the  great  civilized 
nations  of  Europe,  numbering  over  320,000,000  of  inhabitants,  and  covering  3,777,- 
000  square  miles,  which  arc  so  ably  represented  by  the  foreign  members  of  the  Ninth 
International  Medical  Congress;  but  we  may  be  pardoned  for  a brief  allusion  to  our 
North  American  Republic,  with  its  60,000,000  of  inhabitants,  and  its  domain  of 
3,603,000  square  miles. 

Its  active,  restless  population  is  advancing  all  along  the  lines  of  science  and  art, 
converting  the  wilderness  into  cultivated  fields,  with  their  crops  of  golden  gram; 
covering  the  continent  with  railroads,  electric  wires,  and  building  great  cities,  and 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


295 


founding  universities,  asylums,  hospitals  and  museums  of  natural  history  and 
galleries  of  art. 

Her  head  is  pillowed  among  the  icebergs  and  eternal  snows  of  the  Arctic  regions; 
her  feet  are  bathed  in  the  warm  waters  of  the  Gulf  of  Mexico;  her  right  arm 
embraces  the  blue  waters  of  the  Pacific,  and  her  left  the  rolling  billows  of  the  Atlan- 
tic ; her  waist  is  girdled  by  the  rich  mines  of  gold,  silver,  copper,  lead,  iron  and 
coal  of  California,  New  Mexico,  Arizona,  Idaho,  Wyoming,  Utah,  Missouri,  Ken- 
tucky, Tennessee  and  Pennsylvania;  the  great  chain  of  American  Lakes  rest  peace- 
fully on  her  bosom,  and  distill  the  refreshing  showers  which  sustain  her  luxuriant 
corn  and  wheat  fields;  and  her  gigantic  frame  is  supported  by  the  Alleghanies  on  the 
East  and  the  Rocky  Mountains  on  the  West;  from  her  breast  flows  the  mighty  Mis- 
sissippi, watering  her  great  interior  valley,  which  embraces  an  area  of  2,455,000 
square  miles,  more  than  equal  in  area  to  the  whole  continent  of  Europe,  exclusive  of 
Russia,  Norway  and  Sweden,  and  extending  through  thirty  degrees  of  latitude  and 
ninety  degrees  of  longitude. 

In  such  a vast  empire,  reaching  through  such  zones  of  climate  and  ranging 
through  such  degrees  of  elevation,  and  varying  to  such  marked  extent,  in  its  different 
regions,  in  soil,  corresponding  diversities  exist  in  the  diseases  of  different  sections. 

The  home  of  yellow  fever  lies  in  the  West  Indies  and  along  the  coast  of  Central 
America,  and  during  the  warm  months  of  the  year  this  disease  constantly  menaces 
the  cities  of  the  Gulf  and  Atlantic  coasts,  and  this  fact  has  modified  the  systems  of 
quarantine  adopted  by  the  maritime  States  of  this  Republic  : throughout  the  vast 
region  of  the  valley  of  the  Mississippi,  every  form  of  malarial  paroxysmal  fever  pre- 
vails, with  greater  or  less  intensity,  according  to  the  climate  and  soil,  the  heat  and 
moisture,  the  rainfall  and  peculiar  climatic  conditions  associated  with  the  annual 
revolutions  of  the  seasons  and  the  greater  astronomical  cycles. 

From  her  central  position,  forming  the  very  heart  of  the  world,  from  the  char- 
acters of  her  heterogeneous  population  (more  than  one-eighth  of  which  are  descend- 
ants of  the  negro  slaves,  originally  imported  from  Africa),  and  from  her  free  and 
unrestricted  intercourse  with  all  nations  of  North,  South,  Central  and  Insular  Amer- 
ica, of  Europe,  Asia  and  Africa,  the  United  States  of  North  America  should,  of  all 
the  nations  of  the  earth,  be  the  foremost  in  promoting  the  progress  and  perfection  of 
Public  and  International  Hygiene. 

The  speaker  hopes  to  be  pardoned  for  a personal  allusion,  which  brings  in  forcible 
contrast  the  past  and  the  present. 

Twenty-two  years  ago  he  stood  in  the  capital  of  the  United  States  of  America  a 
defenceless  and  friendless  prisoner  of  war,  with  the  home  of  his  fathers  in  ashes,  and 
the  land  which  he  loved  wet  with  the  blood  of  her  sons  and  scarred  and  blasted  all 
over  with  the  thunderbolts  of  war. 

This  day,  after  a generation  has  passed  away,  he  looks  out  upon  fields  of  golden 
grain;  we  hear  the  merry  song  of  the  farmer,  the  hum  of  machinery  and  the  laughter 
of  women  and  children,  and  before  us  we  behold  the  hosts  of  a well-disciplined  army; 
but  we  hear  no  rattle  of  drums  and  no  roar  of  cannon;  the  brazen  trumpet  is  silent, 
and  the  gleam  of  the  bayonet  and  the  flash  of  the  sword  are  seen  no  more. 

The  bright  banner  of  truth  waves  over  these  disciplined  and  valiant  veterans  ; 
their  way  is  guided  by  the  soft  beams  of  the  twin  stars  of  hope  and  love;  and  as  their 
serried  ranks  march  cheerfully  to  mortal  conflict  with  disease  and  death,  each  heart 
throbs  with  the  love  of  humanity,  and  their  lives  are  devoted,  not  to  military  fame  and 
bloody  conquests,  but  to  the  solution  of  the  great  problems  which  relate  to  the  pre- 
servation of  the  lives  and  the  healing  of  the  diseases  of  the  nations  of  the  earth. 


296 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


PUBLIC  AND  INTERNATIONAL  HYGIENE. 

This  branch  of  science  may  be  considered  under  three  main  divisions  : — 

1.  Domestic  Hygiene. 

2.  Public  and  National  Hygiene. 

3.  International  Hygiene. 

We  propose  to  present  a mere  outline  of  this  vast  subject,  in  order  to  bring  into 
bold  relief  questions  of  the  greatest  interest  to  mankind,  which  demand  careful 
investigation. 

Hygiene , a word  derived  from  the  Greek,  means  health ; hygiene  is  the  science, 
and  practical  hygiene  the  art,  of  preserving  health. 

It  is  the  province  of  hygiene  to  seek  out  and  determine  the  causes  of  diseases 
and  to  formulate  rules  for  their  prevention  ; it  may,  therefore,  be  called  Preventive 
Medicine , although  this  name  does  not  include  all  that  must  be  included  under  this 
important  branch  of  science. 

A knowledge  of  the  causes  and  mode  of  propagation  of  diseases  being  necessaiy 
in  order  to  formulate  rales  for  their  prevention,  it  is  evident  that  hygiene  is  largely 
dependent  for  its  perfection  on  the  advances  made  in  chemistry,  physiology,  pathology, 
and  aetiology.  Before  the  discovery  of  oxygen  and  the  determination  of  the  physical 
and  chemical  properties  of  the  atmosphere,  and  its  relations  to  plants  and  animals, 
during  the  last  quarter  of  the  eighteenth  century,  it  was  impossible  to  erect  the 
science  of  hygiene  upon  a broad  and  scientific  basis. 

The  demonstration  of  the  circulation  of  the  blood,  and  the  determination  of  the 
chemical  changes  which  this  fluid  undergoes  during  respiration,  and  of  the  chemical 
properties  and  relations  of  the  constituents  of  the  blood  and  organs  to  the  chemical 
elements  of  the  atmosphere,  earth,  water,  and  food,  were  equally  essential  to  the 
development  of  this  science.  All  scientific  determinations  of  the  relations  of  health 
to  the  amounts  and  kind  of  mental  and  physical  labor  involved  in  our  daily  occupa- 
tions, and  in  the  performance  of  certain  trades  and  callings,  must  rest  upon  the 
determination  of  the  equivalents  of  the  physical  and  chemical  forces  and  upon  their 
mutual  relations  (co-relations). 

While  it  is  true  that  a few  of  the  subjects  embraced  under  the  head  of  practical 
hygiene  have  engaged  the  attention  of  some  of  the  profoundest  thinkers  and  most 
renowned  leaders  of  men  from  an  early  historical  age,  at  the  same  time  it  must  be 
admitted  that  up  to  near  the  close  of  the  last  century  it  rested  almost  entirely  upon 
an  empirical  basis,  by  reason  of  the  imperfection  of  the  collateral  sciences,  and  the 
want  of  those  physical  appliances  and  microscopic  and  chemical  instruments,  reagents, 
and  methods  of  analysis  and  investigation  now  made  available  in  the  nineteenth 
century  for  inquiries  of  such  a difficult  and  recondite  character. 

Within  the  nineteenth  century,  and  especially  during  the  past  fifty  years,  it  has 
been  possible  to  investigate  the  problems  of  hygiene  upon  a strictly  scientific  basis, 
and  to  lay  a foundation  on  which  to  build  a structure  which  may  one  day  enable 
hygiene  to  hold  a place  among  the  more  exact  sciences. 

It  is,  however,  well  established  that,  owing  to  the  advance  in  knowledge  and  the 
improvement  in  the  sanitary  construction  of  dwellings,  towns,  and  cities,  more  abun- 
dant supplies  of  cheap  clothing,  good  water  and  wholesome  food,  the  application  of 
such  preventive  measures  as  vaccination  against  smallpox,  and  a more  enlightened 
system  of  medical  practice,  the  death  rate  of  civilized  nations  has  diminished. 

Two  centuries  ago  the  death  rate  of  London  was  80  per  1000  inhabitants  ; at  the 
present  day  it  is  under  23  per  1000 ; a century  ago  the  navies  of  the  world  could 
hardly  keep  the  sea,  on  account  of  scurvy  ; now,  in  consequence  of  the  discovery  ot 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  297 


the  antiscorbutic  properties  of  lime  juice,  by  Captain  Cook,  and  to  the  use  of  fresh 
canned  meats,  vegetables  and  fruit  on  shipboard,  and  to  the  improvement  in  naval 
architecture  and  hygiene,  scurvy,  ship  fever,  and  even  yellow  fever  are  diseases  of 
the  past,  or  exist  only  as  the  results  of  the  grossest  negligence  on  the  part  of  muni- 
cipal, naval  and  health  officers. 

Jails  and  hospitals  are  no  longer  foul  and  loathsome  hotbeds  of  infectious  and 
contagious  diseases ; the  galling  shackles  have  been  stricken  alike  from  the  feeble 
limbs  of  the  insane,  the  slave  and  the  serf. 

Thirty  years  ago  English  troops  at  home  died  at  the  rate  of  20  per  1000  ; now 
the  death  rate  is  less  than  half  this. 

The  extensive  use  of  quinine  in  the  treatment  of  malarial  paroxysmal  fever  has, 
during  the  past  forty  years,  greatly  reduced  the  rate  of  mortality  from  this  most 
dangerous  and  fatal  fever  in  tropical  and  semi-tropical  regions. 

By  sanitary  regulations  and  by  the  wise  administration  of  quarantine,  Baltimore, 
Philadelphia,  New  York  and  Boston  have,  for  a long  series  of  years  in  this  century, 
banished  yellow  fever  ; and  even  in  our  more  Southern  cities,  as  Charleston,  Savan- 
nah, Mobile,  New  Orleans  and  Galveston,  epidemics  of  yellow  fever  which,  up  to  the 
year  1856,  so  often  ravaged  these  cities,  are  recurring  at  much  longer  intervals  ; and 
an  extended  experience  and  an  intimate  association  with  the  sanitary  affairs  of  our 
Southern  cities  have  led  us  to  the  belief  that  it  will  be  possible,  by  thorough  domes- 
tic sanitation  and  rigid  quarantine,  and  the  proper  regulation  of  commerce  with  the 
West  Indies,  Mexico,  Central  and  South  America,  during  the  months  of  April, 
May,  June,  July,  August,  September  and  October,  by  thorough  disinfection  at  the 
various  foreign  ports,  by  rigid  inspection  of  crews  and  cargoes  and  the  employment 
of  acclimated  crews,  to  banish  this  terrible  scourge  from  the  shores  of  the  United 
States  of  America. 

I.  DOMESTIC  HYGIENE. 

The  family  is  the  unit  of  the  village,  town,  city,  state  and  nation.  From  the 
union  of  man  and  wife,  and  from  the  fruit  resulting  therefrom,  the  nation  has  its  per- 
petual fountain  of  life  and  strength,  from  which  the  ravages  of  war  and  pestilence  and 
the  erosions  of  time  are  healed.  If  the  fountain  be  impure,  the  stream  will  be  foul. 
Households  founded  and  conducted  in  violation  of  the  laws  of  hygiene  are  standing 
menaces  to  the  public  health,  and  the  danger  is  increased  a thousandfold  by  con- 
gregating them  into  towns,  villages  and  cities. 

The  leprous  father  not  only  breeds  a leprous  son,  but  he  menaces  his  neighbors 
with  the  foul  contagion  of  a loathsome  disease. 

Sanitary  education  and  sanitary  reform  must  begin  in  the  household. 

The  conditions  for  health  in  the  household  do  not  differ  materially  from  those  in 
the  village,  town  and  city,  and  may  thus  be  formulated. 

1.  Meteorological  Conditions , or  Climate. — The  temperature  and  the  varying 
amounts  of  moisture,  as  well  as  the  atmospheric  pressure  and  the  character  of  the 
organic  constituents  of  the  air,  appear  to  be  the  most  important  factors  in  the  effects 
of  climate  on  man.  It  must  be  admitted  that  it  is  difficult  to  separate  their  influence 
from  those  of  soil  and  site,  and  much  which  has  been  attributed  to  climate  is  really 
due  to  other  causes. 

If  proper  hygienic  laws  are  carefully  followed  out,  man  may  maintain  his  health 
in  almost  any  climate. 

In  relation  to  human  health,  climate  may  be  considered  as  cold  and  dry,  cold  and 
moist,  temperate  and  dry,  temperate  and  moist,  warm  and  dry,  warm  and  moist,  hot 
and  dry,  hot  and  moist,  malarious  and  non-malarious.  In  hot  and  moist  climates  the 


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NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


agencies  of  disease  appear  to  be  more  easily  called  into  action  than  under  colder  and 
drier  conditions.  Malarial  fevers  appear  to  require  for  their  development  conditions 
of  soil,  vegetation,  moisture  and  temperature,  and  in  their  rise,  spread  and  annual 
declension  are  intimately  associated  with  the  revolutions  of  the  seasons. 

Yellow  fever  had  its  origin  in  the  warm,  moist  climate  of  the  West  Indies  and 
coast  of  Central  America,  and  requires  a certain  temperature  for  its  development 
and  propagation.  The  epidemics  of  this  disease  which  have  occurred  within  the 
limits  of  the  United  States  have  most  generally  attained  their  maximum  mortality 
during  the  heat  of  summer,  and  gradually  declined  in  the  autumn,  until  arrested  by 
the  occurrence  of  a decided  frost. 

Enteric  or  typhoid  fever  exists  under  various  meteorological  conditions,  and  propa- 
gates itself  under  widely  varying  conditions  of  temperature. 

Asiatic  cholera,  although  undoubtedly  originating  in  hot  and  moist  climates  and 
countries,  appears  capable  of  being  propagated  through  the  medium  of  travel  and 
commerce  in  most  parts  of  the  world.  The  invasions  of  Asiatic  cholera  in  South 
and  North  America  have  been  traced  to  infected  vessels,  and  it  has  committed  its 
ravages  at  every  elevation  above  the  sea  and  under  every  vicissitude  of  climate. 

Great  heat  and  dryness  appear  to  arrest  certain  diseases,  as  in  Egypt,  when  the 
plague  was  said  to  cease  after  St.  John’s  day  ; and  during  the  hot  Harmattan  wind 
of  the  west  coast  of  Africa  smallpox  is  arrested,  and  successful  vaccination  is 
impossible. 

Leprosy  and  various  skin  diseases  appear  to  be  characteristic  of  tropical  regions, 
where  also  man  is  tormented  by  a host  of  venemous  insects  and  reptiles.  The  dan- 
gerous Guinea  worm,  the  Hfematobia  bilharzia,  the  cause  of  fatal  disease  of  the 
kidneys  attended  with  profuse  haematuria,  and  the  Filaria  sanguinis  hominis,  the 
prime  factor  in  the  production  of  chyluria  and  Elephantiasis  Arabum,  one  and  all 
appear  to  have  their  home  in  hot,  moist,  tropical  and  semi-tropical  climates. 

It  must  be  observed,  in  this  connection,  that  in  a healthy  body  an  adaptation  to 
circumstances  rapidly  takes  place,  and  an  equilibrium  is  soon  established.  Great 
heat  does  not  necessarily  cause  an  elevation  of  the  temperature  of  the  healthy 
human  body,  and  provided  there  be  no  excess  of  moisture  in  the  surrounding  hot 
air,  the  equilibrium  is  soon  established  and  the  normal  temperature  maintained  by 
the  process  of  transpiration ; should,  however,  this  be  arrested,  then  a rise  of  bodily 
temperature  may  take  place,  and  disease  of  a febrile  character  be  established. 

2.  The  Soil  or  Site  of  the  Dwelling.  — Much  which  has  been  thought  to  be  due 
to  climate,  is  really  referable  to  local  causes,  such  as  the  physical  constitution  of  the 
soil,  defective  drainage,  foul  emanations  and  moisture  exhaled  under  and  around  the 
dwelling. 

Soils  may  be  divided  into  moist  or  dry,  damp  or  wet,  permeable  or  impermeable, 
and  again,  with  reference  to  their  composition  and  geological  formation,  as  silicious, 
sand,  gravel,  clay,  clay  sand  and  gravel  mixed,  alluvium,  made  soil,  slate,  metamor- 
phic,  calcareous,  azoic  and  granite. 

Dry,  permeable  soils  which  allow  of  the  rapid  disappearance  of  rain  water,  which 
are  readily  drained  and  which  are  free  from  organic  matters,  may  be  regarded  as 
suited  to  human  habitation,  especially  if  they  be  removed  from  all  emanations  from 
marsh,  foul  drains,  canals  and  cesspools. 

On  the  other  hand,  soils  composed  of  recently  formed  alluvium,  or  of  the  filth  and 
garbage  of  cities,  or  which  arc  flat,  wet  and  marshy,  are  dangerous  to  human  health, 
and  unfit  for  the  sites  of  dwellings. 

The  air  contained  in  greater  or  less  quantities  in  all  soils  is  impure,  hence  houses 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  299 


should  not  be  constructed  below  the  surface,  or  immediately  on  the  surface  ; and  in 
all  cases  the  earth  under  the  house  should  be  covered  with  some  impervious  material, 
as  asphalt,  cement,  or  slate  ; and  the  impervious  material  should,  if  possible,  be 
laid  upon  a layer  of  gravel  free  from  organic  matter. 

The  amount,  character,  composition,  temperature  and  changes  of  the  water 
naturally  present  in  most  soils  is  of  importance  to  human  health.  Everywhere,  at 
varying  distances  from  the  surface,  there  exists  a great  subterranean  lake  or  sea,  known 
as  subsoil  or  ground  water,  which  is  continually  in  motion,  both  vertically  and  later- 
ally, the  horizontal  movement  being  toward  the  sea  or  nearest  water-course;  the 
vertical  movement  is  chiefly  determined  by  the  rain-fall.  A permanently  high 
ground  water,  that  is  within  five  feet  of  the  surface,  and  frequent  fluctuations  in  the 
height  of  the  ground  water,  are  unfavorable  to  human  health,  while  a permanently 
low  ground  water,  not  less  than  fifteen  feet  below  the  surface,  is  favorable  to  human 
health. 

Pettenkofer  and  his  followers  regard  the  ground  water  as  determining  the  spread 
of  certain  diseases,  as  cholera  and  enteric  fever.  A previously  high  level  succeeded 
by  a fall  in  the  ground  water,  with  a certain  height  of  temperature  in  the  soil  air , 
are  the  conditions  believed  to  be  most  favorable  to  disease  production  and  propa- 
gation. 

3.  The  Materials  of  Buildings. — Circumstances  over  which  the  original  builder 
has  no  control  often  determine  the  character  of  the  materials  used.  The  early  set- 
tlers of  the  forests  of  North  America  found  the  log  cabin  conducive  to  health,  and 
at  the  same  time  capable  of  ready  defence  against  the  attacks  of  the  Indians.  Dwell- 
ings constructed  of  dry  wood  and  well  ventilat  ed  and  exposed  to  the  direct  rays  of  the 
sun,  are  best  for  warm  and  moist  climates,  and  the  only  objection  which  can  be  urged 
against  them  is  their  liability  to  destruction  by  fire. 

Buildings  constructed  of  stone  or  well-burned  brick  may  be  regarded  as  healthy, 
provided  proper  precautions  be  taken  to  secure  dryness  in  the  foundations  and  walls. 
\ arious  opinions  have  been  expressed  as  to  the  advisability  of  constructing  the  walls 
of  inhabited  rooms  of  porous  materials,  or  of  impervious  or  glazed  or  painted  surfaces. 
The  latter  appear  to  be  preferable,  for  where  air  can  penetrate  organic  matters  are 
liable  to  form  a lodgment. 

Papering  may  in  itself  contain  poisonous  materials,  as  arsenic,  while  the  paste 
which  holds  it  to  the  wall  may  undergo  decomposition  and  become  the  source  of  dis- 
ease. Glazed  and  painted  walls  admit  of  repeated  and  thorough  cleansings. 

The  placing  of  a dwelling  on  any  spot  of  ground  tends  to  excite  an  extractive 
force  on  the  soil,  because  the  air  of  the  dwelling  is  almost  always  warmer,  drier  and 
more  rarefied  than  that  of  the  soil,  and  there  is  a constant  danger  of  the  sucking  up 
of  the  impure  air  into  the  dwelling.  An  impervious  foundation  to  dwellings  is  there- 
fore necessary,  to  cut  off  this  recognized  source  of  disease,  which  becomes  very  dan- 
gerous when  the  soil  is  saturated  with  coal  gas,  carbonic  acid  gas,  or  sulphureted 
hydrogen  from  privies  and  cesspools,  or  by  the  putrefying  matters  and  ptomaines  of 
graveyards. 

4.  Drainage  and  Sewerage. — Simple  but  efficient  provision  should  be  made  for 
the  rapid  and  continuous  removal,  not  merely  of  rain  and  storm  water  and  of  that 
employed  in  cooking  and  washing,  but  also  for  the  ground  water. 

All  excrements  and  garbage  should  be  systematically  and  daily  removed,  either 
by  well-constructed  sewers  or  other  well-known  methods.  Under  certain  circum- 
stances cremation  offers  an  effective  mode  for  the  thorough  disposal  of  garbage. 

Filth  must  be  regarded  as  one  of  the  most  important  factors  in  the  development 


300 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


and  propagation  of  disease,  and  it  is  essential  that  it  should  be  continuously  and  sys- 
tematically removed  from  dwellings  and  their  surroundings. 

5.  Ventilation. — Pure  air  should  be  supplied  in  sufficient  quantity  to  each  and 
every  inhabitant  of  the  dwelling.  Proper  air  space  is  of  great  importance  to  the 
construction  of  habitable  rooms,  for  upon  it  depends  the  renewal  of  air.  The  air  of 
a room  can  seldom  be  changed  oftener  than  three  times  an  hour;  and  hence  the 
room  should  be  large  enough  to  allow  of  such  rate  of  exchange  providing  sufficient 
air  for  respiratory  purposes.  Pure  air  constantly  renewed  is  the  prime  necessity  of 
life.  We  may  abstain  from  food  or  water  for  a considerable  length  of  time,  and  thus 
be  enabled  to  replace  either  when  impure,  but  we  must  constantly  breathe  the  atmos- 
phere around  us,  whether  pure  or  impure. 

Air  is  an  admixture  of  oxygen  and  nitrogen,  in  the  proportion  of  about  21  per 
cent,  of  the  former  to  79  per  cent,  of  the  latter,  with  small  proportions  of  carbonic 
anhydride,  moisture  and  organic  matter,  and  microorganisms.  During  respiration 
atmospheric  air  loses  oxygen,  while  the  proportion  of  carbonic  anhydride  and  of 
organic  impurities  is  increased. 

Within  certain  limits,  the  amount  of  carbonic  acid  is  not  injurious  to  health;  it  is 
important  as  a measure  of  the  organic  matter,  which  is  really  the  dangerous  agent; 
air  vitiated  by  respiration  is  hence  more  dangerous  than  when  the  increase  of  car- 
bonic anhydride  is  the  result  of  simple  combustion. 

Air  is  not  fit  for  respiration  when  the  respiratory  impurity,  as  measured  by  the 
carbonic  acid,  much  exceeds  two  parts  in  the  10,000  parts  by  volume.  If  the  air  of 
dwellings  can  be  kept  below  this  point  the  conditions  may  be  regarded  as  satisfactory. 

The  amount  of  impurity  imparted  to  the  respired  air  by  living  beings  must  vary, 
of  course,  with  the  size,  weight,  age,  sex  and  work  performed ; but  it  may  be  estab- 
lished that  six  cubic  feet  of  carbonic  acid  are  given  off  by  each  individual  during  ten 
hours.  This  requires  an  hourly  supply  of  3000  cubic  feet  per  hour  of  fresh  air,  and 
this  amount  should  be  largely  increased  during  work  or  sickness. 

The  diseases  which  have  been  shown  to  be  due  to  imperfect  air  supply,  crowding 
and  impure  air,  are  : consumption,  bronchitis,  malignant  sore  throat,  erysipelas,  puer- 
peral fever,  typhoid  fever,  pyaemia,  and  hospital  gangrene. 

6.  Water  Supply. — The  water  used  for  drinking  and  cooking  should  be  clear, 
tasteless,  odorless,  without  color  or  deposits,  and  free  from  organic  impurities,  and 
should  not  contain  more  than  60  grains  per  gallon  of  such  mineral  salts  as  the  car- 
bonates and  sulphates  of  lime,  magnesia,  soda  and  potassium.  Lead  pipes  and 
lead  cisterns  should  be  abandoned  for  the  storage  or  conveyance  of  drinking  water 
as  endangering  the  health  by  inducing  chronic  lead  poisoning,  ending  in  cramps, 
constipation,  nervous  and  muscular  derangement,  paralysis  and  death. 

The  water  should  be  not  merely  good  in  quality,  but  abundant  in  supply.  Not 
less  than  from  20  to  50  gallons  per  head  should  be  supplied  for  all  purposes,  including 
drinking,  washing,  bathing,  cooking  and  the  removal  of  fecal  matter  by  so  wet’s. 
When  practicable,  the  supply  should  be  continuous,  and  no  supply  pipe  should  com- 
municate with  any  pipe  or  main  leading  to  a sewer  or  cesspool.  In  sparsely  settled 
districts,  water  from  wells  and  springs  may  be  used,  provided  that  care  be  taken  to 
avoid  soakage  from  cesspools,  stables,  barnyards  and  privies.  Deep  wells,  including 
artesian  wells,  cisterns  and  rivers,  uncontaminated  by  the  sewage  of  cities,  often  fur- 
nish good  drinking  water. 

The  purification  of  water  by  filtration  and  other  measures,  for  drinking  purposes, 
is  a subject  of  great  importance,  especially  when  there  is  reason  to  suspect  the  pres- 
ence of  organic  matters  and  the  microorganisms  of  disease.  Without  doubt  the 


wuv,AZO°  ACADEMY 
OR 

medicine. 

SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  301 

waters  of  our  Southern  swamps  and  rice  fields  arc  fruitful  sources  of  the  various  forms 
of  malarial  paroxysmal  fever.  The  use  of  cistern  water,  boiled  and  filtered  water, 
is  essential  to  the  preservation  of  health  on  rice  fields  and  low,  marshy  localities. 

Personal  cleanliness,  so  essential  to  health,  depends  upon  a free  supply  of  pur£ 
water. 

7.  Heating  and  Lighting  of  Dwellings. — The  open  fireplace  has  the  advantage 
of  securiug  good  ventilation,  but  it  is  inadequate  as  a source  of  heat  in  cold  climates. 
Heating  by  coils  of  tubes  or  pipes,  by  means  of  hot  air,  hot  water  or  steam,  is  prefer- 
able to  heating  by  stoves  or  hot-air  furnaces. 

During  the  winter  season  the  temperature  of  sleeping,  sitting  and  work  rooms 
should  not  vary  much — 60°  to  65°  F. 

Sunlight  is  essential  to  health,  and  houses  should  be  so  constructed  as  to  be 
open  to  the  full  rays  of  the  sun. 

8.  Clothing  and  Personal  Cleanliness. — The  clothing  should  be  adapted  to  the 
temperature,  and  should  be  of  such  ample  supply  and  variety  of  character  as  to 
admit  of  frequent  change.  In  warm,  moist  climates  the  under  clothing  should  be 
changed  daily  and  the  entire  body  bathed  in  water.  In  virtue  of  the  increased  pro- 
duction of  cotton  goods  by  machinery,  the  more  extensive  use  of  clothing  and  of 
soap,  the  hygienic  condition  of  civilized  nations  has  vastly  improved  during  the  past 
century,  and  various  diseases,  as  typhus  fever,  the  plague  and  Oriental  leprosy,  have 
ceased  to  commit  extensive  ravages. 

9.  Food. 

10.  Beverages:  Alcohol  and  Alcoholic  Liquors. — The  effects  of  wine,  beer, 
whisky,  brandy,  rum  and  other  intoxicating  drinks  should  not  only  be  the  subject 
of  scientific  investigation,  but  also  of  legislative  enactment. 

11.  Narcotics:  Tobacco , etc. 

12.  Effects  of  Different  Trades. 

13.  Work  and  Exercise. — The  mechanical  work  performed  by  a man  is  usually 
reckoned  as  so  many  tons  lifted  through  one  foot,  called  foot  tons. 

It  has  been  calculated  that  a fair  day’s  work  equals  300  foot  tons,  a hard  day’s 
labor  450  foot  tons,  and  the  maximum  day’s  labor  has  been  fixed  at  600  foot  tons. 
It  must  be  borne  in  mind  that  when  the  amount  of  work  required  exceeds  the  average 
amount  of  it  which  the  human  system  is  capable  of  sustaining,  the  strain  upon  the 
nervous  and  muscular  systems,  and  especially  upon  the  heart,  increases  in  a geomet- 
rical ratio. 

Athletic  and  gymnastic  sports  are  of  great  value  to  young  students,  and,  in  fact, 
to  all  those  who  have  the  opportunity  to  devote  a portion  of  each  day  to  physical 
training ; but  if  the  work  is  excessive,  or  too  violent  and  rapid,  diseased  action  of 
the  heart  and  other  ailments  may  result,  which  may  fatally  diminish  and  impair  the 
nervous,  muscular  and  vital  powers.  Without  doubt,  the  health  of  many  robust 
young  men  has  been  sacrificed  to  over-exertion  in  the  gymnasium  and  in  the  violent 
struggles  for  mastery  in  rowing,  swimming  and  ball  playing. 

14.  Control  and  Regulation  of  the  Sexual  Appetite  and  Relations. 

15.  The  Proper  Conduct  of  the  Period  of  Infancy , including  Food  and  Clothing. 

16.  The  Adjustment  of  Mental  to  Physical  Work. 

This  brief  outline  of  this  important  subject,  embraced  under  the  head  of 
Domestic  Hygiene,  is  sufficient  to  establish  its  importance  as  a branch  of  human 
knowledge,  and  to  demonstrate  the  fact  that  it  underlies  Public , National  and 
International  Hygiene. 


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NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


II.  PUBLIC  AND  NATIONAL  HYGIENE. 

The  principles  of  domestic  hygiene  include  those  of  public  and  national  hygiene. 

The  recognition  of  hygienic  laws  in  the  conduct  of  the  sanitary  affairs  of  towns, 
cities,  hospitals,  prisons,  armies  and  navies  has  been  of  comparatively  recent  date ; 
and  even  at  the  present  day  many  cities  and  States  in  this  republic  are  without 
efficient  health  organizations  and  intelligible  and  practicable  health  laws. 

1.  Boards  of  Health. — It  would  obviously  be  impossible  to  formulate  or  execute 
rules  for  the  guidance  and  protection  of  the  public  health  without  organized  bodies 
charged  with  their  execution. 

In  the  United  States  the  subject  of  public  health  has  been  legislated  by  the 
people,  to  a certain  extent,  as  a police  question,  and  both  local  and  State  boards  of 
health  have  sprung  into  existence.  The  efforts  of  the  general  government  to  legis- 
late on  health  matters  have  been  spasmodic,  and  thus  far  have  not  brought  forth 
the  valuable  fruits,  either  in  measures  or  men,  which  the  citizens  of  a great  republic 
have  a right  to  expect  and  demand.  Health  laws  are  too  often  ambiguous,  of 
doubtful  utility,  and  wanting  in  the  essential  elements  of  clearness  and  power  of 
immediate  execution. 

In  many  cities  the  powers  of  the  municipal  government  and  of  the  board  of 
health  are  not  clearly  defined,  leading  to  divided  responsibility,  neglect  of  duty,  a 
lax  administration  of  sanitary  laws,  and  a shameful  neglect  of  the  public  health. 
This  condition  of  affairs  has  given  rise  to  the  formation  of  so-called  auxiliary  sani- 
tary associations , whose  existence  is  a standing  reproach  to  the  municipal  authorities 
and  boards  of  health,  and  whose  oft-repeated  carping  criticisms  of  the  legally  con- 
stituted authorities,  and  perpetual  appeals  for  money,  have  tended  to  bring  public 
hygiene  into  unmerited  disrepute. 

The  effects  of  divided  authority  and  of  the  uncertain  sounds  of  a multitude  of 
councillors  is  shown  at  the  present  day  in  the  deplorable  condition  and  high  death 
rate  of  many  American  cities,  but  most  conspicuously  in  New  Orleans,  with  its 
entire  sewage  and  drainage  system  of  canals  filled  with  a foul  mass  of  mud,  excre- 
ment and  garbage,  polluting  the  air  with  their  poisonous  vapors,  breeding  diph- 
theria, diarrhoea,  dysentery  and  malarial  fever,  and  causing  the  overflow  of  the 
thoroughfares  by  every  passing  shower. 

The  true  theory  of  this  republican  form  of  government  is  that  the  officers  icho  are 
elected  by  the  votes  of  the  people  are  the  servants , and  not  the  masters  of  the  people ; 
that  laws  were  made  for  the  guidance  of  the  governor  as  well  as  the  governed  ; that 
taxes  are  collected  for  the  use  of  the  taxpayer,  and  not  for  political  parasites  and 
robbers  ; that  an  upright  officer  has  no  discretion  in  the  execution  of  the  law,  which 
is  the  indestructible  and  inexorable  guide  to  his  acts. 

The  people  and  their  servants,  the  officers,  cannot  wisely  or  legally  delegate  the 
execution  of  sanitary  laws  to  voluntary  and  self-appointed  associations,  any  more 
than  they  can  delegate  the  execution  of  judicial  matters  to  irresponsible  parties. 

Health  officers  and  municipal  officers  must  be  held  responsible  for  the  protection 
of  the  public  health  and  the  preservation  of  the  lives  of  the  people  from  all  prevent- 
able causes  of  disease  and  death. 

The  want  of  uniform  health  laws  in  the  States  and  communities  of  the  United 
States  was  clearly  shown  in  the  terror,  alarm,  and  by  the  untold  horrors  of  the  shot- 
gun quarantines  of  the  yellow  fever  epidemic  of  1878,  and  in  the  more  recent  Biloxi 
fever  of  1886.  The  recent  outbreak  of  yellow  fever  at  Key  West,  Florida,  revealed 
the  fact  that  this  great  and  fertile  State,  holding  the  nearest  position  to  the  recog- 
nized home  of  yellow  fever,  was  without  a well-organized  central  board  of  health. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  303 


It  is  manifestly  the  duty  of  the  States  comprising  this  republic,  in  their  sovereign 
capacity  and  in  virtue  of  their  inherent  police  powers  and  their  rights  under  the 
Constitution,  to  meet  together  by  their  chosen  representatives  in  general  convention, 
and  consult  together  on  the  subject  of  public  and  national  hygiene,  including  quaran- 
tine, and  after  careful  and  mature  deliberation  to  frame  and  adopt  a uniform  system 
of  health  and  quarantine  rules  and  laws,  which  shall  be  supreme  over  this  entire 
republic,  and  apply  to  all  emergencies  and  to  all  cases  of  domestic  and  foreign  pes- 
tilence. 

The  police,  sanitary  and  quarantine  powers  and  laws  of  the  individual  and  of  the 
general  government  should  be  clearly  defined,  and  a uniform  system  of  health  and 
quarantine  laws  adopted  by  the  States  and  national  government. 

2.  Vital  Statistics.  — The  advancement  of  public  hygiene  during  the  past  thirty 
years  has  been  largely  due  to  the  increased  attention  paid  by  local  and  general  boards 
of  health  and  by  civilized  governments  to  the  collection,  preservation,  publication 
and  classification  of  vital  statistics.  Foremost  in  this  most  important  work  of  tabu- 
lating the  births,  deaths  and  causes  of  death  must  be  reckoned  the  Registrar  Gen- 
eral of  England,  whose  statistical  work  during  the  past  forty  years  has  influenced 
not  only  England  and  Europe,  but  the  entire  world. 

We  are  now  able  to  determine  the  limits  of  mortality  and  its  causes  with  some 
precision,  and  are  obtaining  correct  data  for  the  interpretation  of  a too  high  death 
rate. 

The  chief  vital  statistics  bearing  upon  public  health  are  : — 

(a)  Determination  of  the  birth  rate. 

(b)  Determination  of  the  general  death  rate. 

(c)  Determination  of  death  rate  according  to  sex,  age  and  disease. 

( d ) Determination  of  the  health  of  classes  of  the  community  as  judged  of  by  their 

expectation  of  life  at  given  ages. 

There  are  many  other  problems,  but  these  are  the  most  important. 

The  collection  of  statistics  of  sickness,  apart  from  mortality,  has  not  hitherto 
been  successful,  on  account  of  the  difficulty  of  collecting  the  data  with  sufficient 
accuracy. 

The  gross  death  rate  is  but  an  elementary  expression  which  should  be  accom- 
panied by  further  analysis  of  mortality  according  to  ages  and  disease,  and  also  by 
considerations  of  the  death  rate.  As  far  as  it  goes,  however,  the  gross  death  rate, 
without  distinction  of  age,  sex  or  disease,  has  shown  valuable  uses  in  the  institution 
of  comparisons  in  the  mortality  of  different  localities,  seasons  and  years. 

It  has  thus  been  assumed  in  England  and  other  countries  that  the  death  rate  is 
nowhere  satisfactory  if  it  exceeds  23  per  annum  per  1000  of  population. 

In  the  United  States,  as  well  as  in  all  civilized  countries,  the  progress  and  per- 
fection of  public  and  national  hygiene  will  be  advanced  by  the  following  regulations: — 

(a)  Careful  registration  of  all  physicians,  midwives  and  undertakers. 

(b)  Regulation  by  law  of  the  practice  of  the  medical  profession. 

(c)  Scientific  and  uniform  classification  of  all  diseases  and  causes  of  death. 

( d ) Forms  for  the  systematic  reports  of  births,  giving  sex,  race  and  condition. 

(e)  Forms  for  reports  of  deaths,  giving  age,  place  of  death,  date  of  death,  cause 

of  death,  sex,  occupation,  condition,  length  of  illness,  birthplace,  etc. 

(/)  Record  of  marriages,  giving  age,  race  and  condition. 

The  system  of  registering  vital  statistics  should  be  uniform  throughout  the  civil- 
ized world,  and  should  in  all  cases  give  data  for  the  calculation  of  the  following  : 
Number  of  the  population  and  of  various  persons  of  various  races,  ages,  sexes 


304 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


and  occupations  ; the  number  of  deaths,  the  sex,  ages  and  condition  of  the  persons 
dying  and  the  diseases  causing  the  mortality. 

The  national  census  furnishes  some  of  these  figures,  and  the  medical  profession 
furnish  the  rest.  A very  great  responsibility,  therefore,  rests  upon  the  medical  pro- 
fession, for  the  proper  regulation  of  public  hygiene,  by  pointing  out  the  effects  of 
locality,  trade,  occupation,  diet,  water,  crowding  and  heredity  upon  the  mortality 
of  different  classes  and  at  different  ages. 

3.  Relations  of  Race  to  Public  Hygiene  and  to  the  National  Death  Rate. 

The  political,  social  and  sanitary  problems  presented  by  the  negro  race  in  the 
United  States  of  America  are  of  the  gravest  character,  and  remain  unsolved. 

The  African  slave  trade,  established  by  British  rulers,  conducted  by  British  slavers 
and  fostered  by  New  England  merchants,  New  England  capital  and  New  England 
seamen,  transported  to  the  shores  of  the  English  colonies  a black,  barbaric  race,  with 
strong  physical  characters  and  race  peculiarities,  but  destitute  of  learning,  arts,  civil- 
ization or  historic  fame. 

The  negroes  slowly  but  steadily  gravitated  to  the  Southern  States,  which  were 
better  adapted,  by  soil,  climate,  and  peculiar  productions,  to  slave  labor. 

The  concentration  of  the  slaves  in  the  States  of  Maryland,  Virginia,  North  Caro- 
lina, South  Carolina,  Georgia,  Florida,  Alabama,  Mississippi,  Louisiana,  Texas, 
Arkansas,  Missouri,  Tennessee  and  Kentucky,  led  to  sectional  peculiarities,  senti- 
ments, prejudices  and  politics,  which  finally,  through  the  perpetual  agitation  of  the 
abolitionists,  led  to  sectional  hatred ; uncompromising  hatred  finally  led  to  bloody, 
relentless,  fratricidal  warfare.  If  the  States  of  this  Republic  had  been  guided  by  the 
counsels  of  great,  good  and  wise  statesmen,  the  bloody  Civil  War  of  1861-65,  with  its 
million  of  slain  and  its  billions  of  lost  treasure,  would  never  have  taken  place,  but 
would  have  been  superseded  by  a wisely  devised  system  of  gradual  emancipation, 
which  would  have  left  these  people  free,  happy,  prosperous  and  united,  and  the  soil 
of  the  Republic  would  have  been  unpolluted  by  the  blood  of  her  sons. 

Transported  from  slavery  to  freedom,  not  by  their  own  power  or  prowess,  the 
negro  slaves  were  called  upon  to  assume  new  duties  and  to  play  a new  role  in  the 
march  of  civilization,  in  the  heart  of  a great  nation  of  white  men,  with  different  race 
peculiarities,  manners,  customs,  traditions  and  moral  and  intellectual  endowments. 

We  believe  it  to  be  the  duty  of  the  stronger  race  to  protect  the  weaker ; at  the 
same  time  we  do  not  believe  that  the  progress  of  civilization  on  this  continent  will 
ever  be  checked  by  the  domination  of  the  white  race  by  the  negro  or  the  Chinese. 
No  greater  crime  can  be  conceived  or  perpetrated  in  the  annals  of  humanity  than 
the  amalgamation  and  mongrelization  of  a superior  with  an  inferior  and  barbaric 
race,  or  the  political  subjection  of  the  former  to  the  latter. 

This  is  not  the  time  or  the  place  for  the  discussion  of  political  and  social  prob- 
lems, and  we  pass  at  once  to  the  brief  consideration  of  the  influence  of  race  on  the 
gross  mortality  of  this  country. 

In  the  United  States  census  for  1880  we  find  that  in  a population  of  43,402,970 
whites  there  are  recorded,  for  the  year  1880,  640,191  deaths,  giving  a mortality  of 
14.74  per  1000  inhabitants. 

In  a population  of  6,752,813  colored,  there  were  recorded  116,702  deaths,  giv- 
ing a mortality  of  17.28  per  thousand. 

Taking  the  States  east  of  the  Mississippi  river  which  have  the  largest  popula- 
tion of  colored  people,  namely,  Alabama,  District  of  Columbia,  Florida,  Georgia, 
Kentucky,  Maryland,  Mississippi,  North  and  South  Carolina,  Tennessee,  Virginia 
and  Louisiana  (including  in  this  latter  State  that  part  west  of  the  river  also),  we  find 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  305 

that  the  total  white  population  is  8,530,962,  and  the  number  of  deaths  of  whites 
recorded  113,110,  giving  a death  rate  of  14.4  per  thousand. 

The  colored  population  of  the  same  States  was  given  as  5,303,267,  and  the  num- 
ber of  deaths  among  them  reported,  91,328,  giving  a death  rate  of  17.22  per 
thousand. 

In  this  section  of  the  country  the  deficiencies  of  the  enumerators’  returns  of 
deaths  are  above  the  average,  and  they  are  greater  than  for  the  white  race,  so  that 
the  deficiencies  between  the  mortality  rates  of  the  two  races  is  greater  than  that 
indicated  above. 

In  the  Southern  States  the  ratio  of  mortality  is  greater  among  the  colored  people 
than  among  the  whites,  in  the  ratio  of  17.29  colored  to  14.4  white  per  1000 
inhabitants. 

In  the  same  group  of  Southern  States  referred  to,  over  one-half  the  deaths 
reported,  or  507. 10  per  thousand  deaths,  occur  under  five  years  of  age.  Of  the  col- 
ored females,  438. 47  per  thousand  deaths  are  reported  under  five  years  of  age.  The 
proportion  is  less  in  the  white  race. 

This  excess  of  infantile  mortality  in  the  colored  race  occurs  in  each  grand  group 
in  which  the  distinction  of  color  is  made,  and  is  the  main  cause  of  the  excess  of 
mortality  in  the  colored  race  over  the  white. 

The  mortality  in  the  colored  race  is  greatly  increased  in  the  large  cities  of  the 
United  States,  as  will  be  illustrated  by  the  following. 

The  statistics  of  Savannah,  G-eorgia,  as  far  as  I have  been  able  to  examine  them, 
are  as  follows  : — 


SAVANNAH,  GEORGIA:  TOTAL  DEATHS  FROM  ALL  CAUSES  IX  WHITE  AND 

BLACK  RACES. 


Years. 

Total  Deaths. 
White. 

Total  Deaths. 
Black. 

White  and  Black. 
Total. 

1854 

1221 

308 

1529 

1855 

433 

292 

725 

1856 

466 

297 

763 

1857 

376 

264 

640 

1858 

592 

262 

854 

1859 

430 

273 

703 

1860 

474 

282 

756 

1861 

563 

269 

832 

1862 

555 

372 

927 

1863 

459 

389 

848 

1864 

747 

446 

1193 

1865 

1202 

819 

2021 

1866 

530 

912 

1442 

1867 

476 

594 

1070 

1868 

498 

581 

1079 

1869 

423 

429 

852 

Total  deaths  from  1856  to  1869,  16,234. 

The  whites  appear  to  be  in  excess  of  the  colored  population  in  Savannah,  and  the 
mortality  is  greater  in  proportion  to  the  population  of  the  latter. 

In  New  Orleans,  Louisiana,  the  colored  race  forms  a larger  proportion  of  the  pop- 
ulation than  in  any  other  American  city.  We  have  established,  by  carefully  recorded 
statistics,  now  in  the  possession  of  the  Board  of  Health  of  the  State  of  Louisiana, 

that  the  death  rate  of  the  colored  race  exceeds  that  of  the  whites  in  the  cities  of  the 
Vol.  IV — 20 


30G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


United  States,  no  matter  where  the  statistics  be  gathered,  whether  in  southern  or 
northern  regions.  As  we  have  examined  the  statistics  of  New  Orleans  more  fully 
than  those  of  other  American  cities,  we  give  the  gross  results  of  the  investigations 
illustrating  the  mortality  of  New  Orleans  for  a series  of  years  in  the  following  table, 
giving  the  rate  of  mortality  per  1000  white,  colored  inhabitants,  and  total  mortality. 


MORTALITY  OF  NEW  ORLEANS.  LOUISIANA— DEATH  RATE  PER  1000 

INHABITANTS. 


Year. 

White. 

Colored. 

Total. 

1845 

25.10 

22  50 

24.32 

1847 

70.86 

37.08 

62  03 

1849 

81.92 

62.91 

77.44 

1850 

63.08 

52.10 

59.38 

1852 

67.91 

43.04 

62.90 

1853 

124.68 

48.98 

100.09 

'1856 

32.98 

35.66 

33.89 

1857 

34.86 

38.07 

35.49 

1858 

69.64 

80.37 

72.70 

1859 

33.58 

86.78 

41.53 

1860 

41.99 

52.79 

43.51 

1861 

31.58 

37.16 

31.87 

1863 

37.30 

59.53 

41.35 

1864 

42.14 

81.75 

49.86 

1865 

33.32 

60.88 

38.99 

1866 

36.77 

65.56 

42.52 

1867 

56.79 

47.80 

54.69 

1868 

25.49 

38.97 

28.60 

1869 

27.29 

44.80 

31.75 

1870 

33.74 

52.20 

38.61 

1871 

27.26 

42.76 

31.32 

1872 

27.29 

41.93 

31.17 

1873 

32.79 

51.42 

37.73 

1874 

29.53 

43.44 

33.75 

1875 

26.28 

40.25 

30.00 

1876 

25.87 

42.50 

30.31 

1877 

25.96 

49.02 

32.11 

1878 

52.05 

39.94 

48.81 

1879 

20.85 

32.41 

23.95 

1880 

22.96 

34.38 

26.01 

1881 

25.79 

38.95 

29.31 

1882 

21.89 

39.03 

26.45 

During  a period  of  thirty-two  years  embraced  in  the  above  table,  with  the  excep- 
tion of  1879,  the  death  rate  among  the  whites  was  the  lowest  in  1882.  The 
average  death  rate  for  the  thirty-two  years  among  the  whites  was  about  39.6  per 
thousand,  for  the  colored  about  47. 1 per  thousand. 

These  statistics  establish  the  fact  that  the  death  rate  among  the  colored  popula- 
tion is  heavier  than  among  the  white. 

There  was  a marked  diminution  of  the  death  rate  among  the  whites,  and  also 
among  the  colored  during  the  year  1879  to  1882  inclusive;  this  diminution  was 
largely  due  to  the  sanitary  operations  of  the  Board  of  Health  of  the  State  of  Louisi- 
ana, and  to  the  thorough,  rigid  and  scientific  system  of  quarantine  established  and 
maintained  during  the  period  which  I held  the  position  of  President  of  the  Board. 
The  results  of  the  rigid  system  of  quarantine  and  of  domestic,  public  and  maritime 


SECTION  XV — TOBLIC  AND  INTERNATIONAL  HYGIENE.  307 


sanitation  conducted  during  the  years  1880-83  by  the  Board  of  Health,  lead  us  to 
hope  that  foreign  pestilence  may  be  forever  excluded  from  the  valley  of  the 
Mississippi. 

As  to  the  causes  of  the  greater  mortality  of  the  colored  race  in  Southern  cities,  as 
far  as  our  observations  have  exteuded,  they  appear  to  be  as  follows: — 

(1)  The  negro  has  been  but  comparatively  recently  enfranchised,  and  is  in  a tran- 
sition state;  freedom  coming  by  the  violent  cataclasm  of  war  and  civil  revolution 
found  him  uuprepared,  to  a large  extent,  to  reap  its  benefits.  How  long  it  will 
require  the  negif>  to  obtain  the  necessary  sanitary  knowledge  to  reduce  his  death 
rate  to  the  minimum  is  a question  for  the  future.  That  he  has  not  yet  attained  this 
knowledge  is  known  to  every  careful  and  conscientious  observer.  That  he  has  failed 
to  accumulate  any  large  amount  of  property,  as  a race,  during  his  twenty-two  years 
of  freedom  is  well  known. 

(2)  Poverty  and  ignorance  breed  dissolute  habits,  engender  imprudence,  and 
directly  and  indirectly  breed  disease  from  poor  diet,  crowding,  and  the  violation  of  all 
known  sanitary  laws.  Health  is  incompatible  with  crowding  and  filth.  The  destruc- 
tive effects  of  poverty,  poor  diet,  crowding,  scanty  clothing  and  filth  and  neglect  are 
especially  manifest  in  the  high  death  rate  among  negro  children. 

(3)  While  the  better  classes  of  the  colored  people  bind  themselves  together  in 
societies  for  mutual  aid,  and  employ  physicians  for  the  sick,  and  furnish  medicine  as 
well  as  food  for  the  sick  and  destitute,  large  numbers,  especially  those  crowding  into 
the  cities  from  the  surrounding  plantations,  enjoy  no  advantages  of  this  kind,  and 
too  frequently  are  crowded  together  in  the  hovels  of  the  purlieus. 

(4)  Vice  and  alcoholic  stimulants  are  potent  factors  among  the  latter  class, 
including  the  roustabouts  (steamboat  hands),  who  frequent  low  drinking  and  gam- 
bling hells  and  obscene  dance  houses  in  the  slums  of  certain  parts  of  the  city. 

(5)  Crowding  and  improper  food,  and  in  many  cases  absence  of  medical  attend- 
ance and  insufficiency  of  clothing  and  fuel  during  the  winter  months,  without  doubt 
largely  increase  the  mortality  rate,  especially  among  the  colored  children. 

(6)  The  neglect  of  Vaccination  by  the  colored  race  makes  them  peculiarly  liable  to 
the  ravages  of  smallpox,  as  I have  shown  by  statistics  collected  during  the  last  forty 
years.  Owing  to  a large  population  of  probably  now  over  60,000  colored  people 
(U.  S.  census  of  1880:  white,  158,367;  colored,  57,723;  total,  216,090),  New 
Orleans  is  perpetually  exposed  to  epidemics  of  smallpox  whenever  this  disease  is 
introduced  into  the  United  States.  The  incubative  period  of  smallpox  being  four- 
teen days,  the  negroes  from  the  surrounding  plantations  who  visit  the  city  bring  in 
their  persons  the  seeds  of  the  disease. 

(7)  Statistics  show  that  in  the  country  outside  of  the  city,  the  negro  is  very  pro- 
lific, and  that  the  race  is  increasing,  notwithstanding  the  large  death  rate  in  the  city. 
The  early  period  at  which  the  negro  women  begin  to  bear  children,  and  the  frequency 
with  which  illegal  sexual  intercourse  takes  place  in  this  race  also  cause  an  increase 
in  the  birth  rate  in  the  agricultural  districts  of  the  Southern  States. 

4.  Location  of  Towns  and  Cities. — Dwellings  should  be  scattered  over  as  large  an 
area  as  possible,  for  sickness  and  death  are  often  in  proportion  to  the  amount  of  area 
per  head  occupied  by  a community.  The  area  per  head  of  the  population  of  London 
Is  estimated  as  double  that  of  Paris  and  many  other  cities,  while  at  the  same  time  its 
death  rate  is  smaller  than  that  of  any  other  large  city  in  Europe. 

The  comparatively  large  rate  of  mortality  of  New  York  city  is  largely  due  to  the 
crowded  condition  of  its  population,  which  appears  to  increase  with  the  growth  of 
the  city.  New  Orleans,  notwithstanding  its  situation  in  a low,  marshy,  ill-drained 

i 


310 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  vast  importance  of  this  subject  to  our  American  cities  is  shown  by  the 
following  facts  and  figures  relative  to  the  diseases  which  cause  the  chief  mortality  in 
New  Orleans. 

During  the  past  55  years,  in  the  great  Charity  Hospital  of  New  Orleans,  there 
have  been  admitted  476,188  patients,  of  which  number  355,996  have  been  discharged, 
with  a mortality  of  62,380,  or  14.7  per  cent.  The  mortuary  record  of  New  Orleans, 
during  34  years  (1844-1880),  with  the  exception  of  two  years  (records  incomplete), 
shows  that  the  total  deaths  were  242,426,  and  of  this  number  phthisis  pulmonalis 
occasioned  24,071.  During  the  period  just  specified  (1844-1880),  34  years,  the  prin- 
cipal diseases  occasioned  the  number  of  deaths  shown  by  the  following  table  : — 


Deaths  in  New  Orleans,  Louisiana,  from  Some  of  the  Principal  Causes, 
During  a Period  of  Thirty-four  Years,  1844-1880. 


Cholera  (Asiatic) 11,847 

Cholera  Morbus 889 

Cholera  Infantum 2,408 


Total 15,144 

Enteritis 6,915 

Diarrhoea 8,289 

Dysentery 7,097 


Total 22,301 

Phthisis  Pulmonalis 24,071 

Smallpox,  Scarlet  Fever  and  Measles 9,381 

Dengue,  Typhoid,  Typhus  Fever,  Cerebro-Spinal  Fever  and 

simple  Continued  Fever 5,932 

Yellow  Fever 28,739 

Various  forms  of  Malarial  Fever 12,416 


Total 


56,468 


While  fevers  of  all  varieties  destroyed  in  the  city  of  New  Orleans  56,478  citizens 
in  34  years,  yellow  fever  destroyed  only  one-half  of  that  number,  namely,  28,739  ; 
and  notwithstanding  the  fact  that  only  about  one-half  of  the  mortality  from  fever 
in  New  Orleans,  during  the  perioj  specified,  was  due  to  yellow  fever,  the  attention 
of  the  citizens  of  the  entire  Mississippi  valley  has  been  and  is  directed  to  this  disease. 

Congestive  fever  alone  occasioned  in  New  Orleans,  during  34  years,  6337  deaths. 
Phthisis  pulmonalis  destroyed  nearly  as  many  citizens  as  yellow  fever,  namely,  24,071 ; 
enteritis,  dysentery  and  diarrhoea,  22,301,  and  cholera,  cholera  morbus  and  cholera 
infantum,  15,144.  Total  deaths  from  phthisis  pulmonalis  and  bowel  affections,  61,516. 

These  diseases,  which  are  common  to  the  entire  valley,  caused  61,516  deaths, 
exceeding  those  caused  by  fevers,  which  were  56,478.  Fevers,  bowel  affections  and 
phthisis  pulmonalis  alone  caused  in  New  Orleans  1 17,994  deaths  in  34  years,  out  of 
a total  of  deaths  from  all  causes  of  242,426. 

6.  Structure , Hygienic  Arrangements  and  Ventilation  of  Buildings. 

(a)  Proper  condition  of  the  soil  for  the  location  of  buildings. 

( b ) Size  and  arrangement  of  streets,  squares,  courts,  etc. 

(c)  Relations  of  building  materials  to  moisture,  heat  and  cold. 

(d)  Public  buildings,  legislative  halls,  depots,  churches. 

(e)  Schoolhouses  and  colleges. 

(/)  Factories. 

(g)  Dwellings. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


311 


All  streets,  sidewalks  and  courts  should  be  paved  with  brick,  granite,  slate,  asphalt, 
limestone  or  other  impervious  and  hard  material.  Wooden  pavements  have  proved 
useless  ana  dangerous  to  health  in  New  Orleans  and  Memphis.  Wooden  pavements 
in  warm,  moist  climates  undergo  gradual  but  steady  decay,  and  absorb  the  urine  and 
liquid  excreta  of  man  and  animals.  The  square  block,  New  England  granite,  has 
proved  the  most  useful  and  durable  pavement  in  New  Orleans. 

In  such  large  cities  as  New  Orleans,  excellent  streets  may  be  constructed  of  the 
hard,  silicious,  coarse,  concrete  gravel  of  the  hills  of  Louisiana  and  Mississippi.  This 
gravel,  free  from  organic  matter,  also  forms  an  admirable  material  for  the  filling  and 
elevation  of  lots.  For  roadways  it  appears  to  be  superior  to  the  oyster  and  lake 
shell,  in  that  it  creates  less  dust,  is  more  indestructible  and  forms  a harder  and 
smoother  road. 

Streets  should  be  at  least  twice  as  wide  as  the  height  of  the  tallest  houses,  and 
should  allow  of  a free  passage  of  air  to  all  parts  of  towns  and  cities ; vacant  squares 
and  courts  add  to  the  air  space  and  prove  of  great  value  for  the  dilution  and  purifi- 
cation of  the  air.  There  should  be  open  spaces  at  the  back  of  the  houses,  and  back 
to  back  buildings  should  be  absolutely  prohibited;  upon  any  given  square  of  ground 
the  vacant  spaces  should  exceed  those  occupied  by  the  houses. 

It  is  difficult  to  determine  the  exact  number  of  people  who  can  be  crowded  upon 
any  given  space  of  ground,  as  an  acre  or  square  mile.  The  degree  of  crowding  which 
may  be  compatible  with  the  public  health  will  be  largely  determined  by  the  struc- 
ture, height  and  arrangement  of  the  individual  houses,  and  the  peculiarities  of 
climate.  All  houses  should  be  ventilated,  both  vertically  and  laterally,  and  no  room 
should  have  a borrowed  light,  but  each  room  should  have  windows  open  directly 
upon  the  exterior  for  light  and  fresh  air.  Rooms  should  be  of  sufficient  height,  from 
ten  to  twelve  feet,  and  of  sufficient  size,  from  fifteen  to  eighteen  feet  square.  Great 
attention  should  be  paid  to  the  ventilation  of  the  closets,  which  should  be,  as  far  as 
possible,  detached  from  the  main  building  and  furnished  with  their  own  arrangements 
for  ventilation. 

Without  doubt  certain  contagious  and  infectious  diseases,  as  Asiatic  cholera, 
scarlet  fever  and  diphtheria,  have  been  communicated  by  means  of  the  foul  air  of 
badly  constructed  sewers,  from  house  to  house. 

7.  Water  Supply — Relations  of  Water  to  the  Public  Health. 

(a)  Properties  of  wholesome  potable  water. 

(b)  Water  supply  of  cities. 

(c)  Proper  supply  of  water  for  each  inhabitant. 

(cl)  Filtration  and  purification  of  water. 

(e)  Transmission  of  disease  germs  through  the  medium  of  water. 

In  towns  with  sewers  and  water  closets,  it  has  been  reckoned  by  sanitarians  that 
the  supply  of  water  daily,  per  head,  should  not  be  less  than  twenty-five  gallons,  and 
if  there  are  trades  using  water,  from  five  to  fifteen  gallons  more  additional  to  each 
inhabitant.  If  there  are  no  water  closets,  from  fifteen  to  twenty  gallons  are  com- 
monly deemed  necessary. 

(/)  An  accurate  chemical  analysis  should  be  made  of  all  waters  used  for  drinking 
in  each  and  every  town  or  city. 

(g)  A careful  determination  should  be  made  of  the  relations  of  the  water  to  lead, 

iron,  tin  and  terra-cotta  pipes. 

(h)  The  supply  of  water  should  be  abundant,  and  sufficient  for  all  emergencies  of 

drought  or  fire. 

(i)  The  water  supply  should  not  be  liable  to  any  contamination  whatever. 


312 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


O')  The  water  should  be  clear,  colorless,  odorless  and  tasteless.  It  should  contain 
no  injurious  amount  of  organic  matter,  not  exceeding  two  or  three  grains 
per  gallon ; and  the  mineral  constituents  should  not  exceed  fifty  grains 
per  gallon,  and  should  be  composed  chiefly  of  chlorides  and  sulphates  of 
the  alkalies  and  alkaline  earths,  which  are  not  injurious. 

It  is  not  so  much  the  amount  of  organic  matters  present  in  drinking  water,  as  the 
presence  or  absence  of  disease  germs  and  of  the  products  of  the  putrefaction  of  vege- 
table and  animal  matters.  The  sources  of  supply  of  the  water,  whether  springs, 
wells,  streams,  lakes  or  gathering  grounds,  should  be  carefully  investigated. 

In  towns  of  any  size  all  superficial  wells  are  dangerous  sources  of  drinking 
water,  in  that  they  are  largely  supplied  with  water  drawn  from  the  surface  and  con- 
taminated with  filth  from  privies,  garbage  and  the  streets,  gutters  or  manufactories 
of  cities. 

Questions  relative  to  filtration,  and  with  reference  to  the  continuous  or  intermit- 
tent supply  of  water,  should  be  considered  with  the  greatest  care. 

8.  Food  and  its  Adulterations — Food  Supply — Markets — Slaughter  Houses , Meat 
and  Sausage  Factories — Bread  and  Bakeries — Confectionery— Canned  Food  and 
Canned  Vegetables — Canned  Milk— Milk  and  its  Adulterations. 

(a)  Diseased  meat  as  a medium  of  propagating  certain  contagious,  infectious  and 

parasitic  diseases. 

(b)  Methods  of  inspecting  live  animals  designed  for  human  food. 

(c)  Inspection  of  the  meat  of  slaughtered  animals,  including  the  use  of  the 

microscope. 

(d)  Inspection  of  milk  and  its  products.  Milk  as  a medium  of  the  transmission 

of  various  diseases,  as  diphtheria,  scarlet  fever,  etc. 

(e)  Influence  of  dilferent  methods  of  preserving  food  on  the  public  health. 

(/)  Influence  of  canned  food  upon  the  public  health. 

(g)  The  injurious  elfects  of  lead,  copper,  tin,  zinc  and  antimony  upon  food,  said 
metals  being  used  for  culinary  vessels,  dishes,  receptacles,  cans  and  solder. 

Each  town  or  city  should  have  one  or  more  competent  medical  and  chemical 
officers,  who  should  be  charged  with  the  continuous  and  careful  inspection  and 
examination  of  all  markets,  all  articles  of  food,  including  meats,  the  products  of 
grain,  fruits,  milk,  canned  vegetables,  and  preserves.  These  officers  should  be  com- 
pelled to  condemn  all  adulterated  articles  of  food,  and  to  punish  offenders. 

Each  civilized  nation  should  establish  a thorough  system  of  inspection  of  the 
manufactories  and  the  products  of  canned  goods.  Every  can  of  vegetables,  fruit  or 
meat  should  have  the  precise  date  of  the  manufacture  stamped  upon  it.  At  the 
periodical  inspection  of  canned  goods,  all  imperfect  goods  should  be  destroyed.  It  is 
a question  to  be  determined  whether  the  alleged  increase  of  Bright’s  disease  and  of 
certain  forms  of  paralysis  has  been  caused  by  the  extensive  use  of  canned  goods,  and 
of  syrup  manufactured  from  cellulose  by  the  action  of  sulphuric  acid. 

All  coloring  matters  used  in  the  preparation  of  certain  kinds  of  food  and  pre- 
serves, and  in  the  manufacture  of  wines  and  beverages,  should  be  the  subject  of  care- 
ful scientific  investigation  at  the  hands  of  competent  medical  officers  and  chemists. 

9.  The  Influence  of  Alcohol  on  the  Public  Health. 

(a)  Wine. 

(b)  Malt  liquors. 

(c)  Distilled  liquors. 

(d)  The  relations  of  alcohol  to  muscular  and  intellectual  work. 

(e)  The  value  of  alcohol  in  the  treatment  of  disease. 


SECTION  XV — rUBLIC  AND  INTERNATIONAL  HYGIENE.  313 


(/)  The  adulteration  of  wine,  malt  liquors  and  distilled  liquors. 

(g)  Inspection  and  analysis  of  liquors. 

(/<)  The  relations  of  alcohol  to  crime. 

(t)  The  relations  of  alcohol  to  the  production  and  increase  of  insanity. 

10.  The  Influence  of  Narcotics  on  the  Public  Health — The  Unrestrained 'Sale  of 
Poisons  and  Patent  Secret  Medicines. 

(a)  Tobacco. 

( b ) Cannabis  Iudica,  etc. 

(c)  Opium  and  its  preparations. 

(d)  Chloral  hydrate  ; chloroform  and  ether  ; cocaine,  etc. 

(e)  Patent  medicines  whose  composition  is  kept  secret. 

(/)  The  unrestricted  sale  of  poisons  and  patent  and  proprietary  medicines  by 

druggists. 

In  this  republic  the  unrestrained  sale  of  poisons,  poisonous  drugs,  and  of  secret 
patent  and  proprietary  compounds  is  a great  and  growing  evil,  which  should  be  sum- 
marily suppressed  by  carefully  enacted  laws  on  the  part  of  the  State  and  general 
governments.  The  manufacturers  of  patent  and  proprietary  medicines,  and  of 
various  elixirs  (more  or  less  strong  compounds  of  alcohol),  and  sugar-coated  pills 
(the  composition  and  strength  of  which  depend  entirely  upon  the  will  and  honesty 
of  the  manufacturer),  have  attained  sufficient  power,  not  merely  to  control  the  local 
druggists,  but  even  to  subsidize  a considerable  portion  of  the  medical  press.  It  is  at 
this  day  by  no  means  uncommon  to  observe  the  advertisements  of  proprietary  medi- 
cines sandwiched  between  the  pages  of  articles  on  medical  subjects  in  American 
medical  journals. 

It  is  well  known  that  numerous  cases  of  fatal  poisoning  have  been  traced  to  the 
unrestrained  sale  of  poisons  by  druggists. 

11.  Effects  of  Trades  and  Manufactures  on  the  Public  Health. 

(a)  Relative  effects  of  agriculture  and  of  trades  on  the  longevity  and  health  of 

the  people. 

( b ) Detailed  statement  of  the  effects  of  various  trades  on  the  health. 

(c)  Effects  of  the  introduction  of  machinery  upon  the  longevity  and  health  of  the 

people. 

(d)  Effects  of  manufactures  upon  the  atmosphere  and  waters  of  towns,  villages 

and  cities. 

(e)  Effects  of  various  manufactures  upon  the  public  health. 

(/)  Influence  of  coal  gas  upon  the  public  health. 

( g ) Influence  of  the  electric  light  on  the  public  health. 

12.  Structure  and  Arrangement  of  Prisons  and  the  Treatment  of  Prisoners. 

(a)  Treatment  of  prisoners  ; food,  clothing  and  occupation. 

( b ) Sanitary  regulations  of  prisons,  jails. 

(c)  The  relations  of  prison  labor  to  free  labor. 

(d)  Has  the  State  the  right  to  work  prisoners  in  swamps  and  marshes  and  to  cause 

the  destruction  of  human  life  by  the  neglect  of  all  the  laws  of  hygiene  ? 

(e)  Are  not  deaths  occasioned  by  cruelty,  overwork,  scant  clothing,  poor  food  and 

exposure,  directly  chargeable  against  the  officials  composing  the  govern- 
ment, whether  acting  in  behalf  of  a city,  county,  State  or  nation? 

1 3.  Influence  of  the  Modern  Style  of  Travel  on  the  Public  Health. 

(a)  Effects  of  railroad  travel  in  inducing  paralysis. 

(b)  Hygienic  structure  and  conduct  of  railroad  trains,  so  as  to  avoid  the  intro- 

duction and  dissemination  of  infectious  and  contagious  diseases. 


314 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Oriental  leprosy, 
Oriental  plague, 
Elephantiasis, 
Smallpox. 


(c)  Conduct  of  railroad  trains  and  travel  during  epidemics  of  yellow  fever,  small- 

pox, and  Asiatic  cholera. 

(d)  Structure  and  arrangement  of  sailing  and  steamships. 

(e)  Hygienic  regulations  of  officers,  crews  and  passengers. 

(/)  .The  sanitation  of  ships  so  as  to  avoid  the  introduction  of  contagious  and 
infectious  diseases. 

(g)  Methods  of  disinfection  best  adapted  to  purify  railroad  cars  and  ships. 

(h)  Disinfection  of  infected  cargoes  and  clothing. 

14.  Influence  of  Agriculture  on  the  Public  Health. 

(a)  Influence  of  overflows  on  the  public  health. 

(h)  Importance  of  drainage  ; drainage  of  swamps,  marshes,  and  land  generally. 

(c)  Influence  of  the  cultivation  of  rice  on  the  public  health. 

(< d ) Influence  of  cotton,  tobacco,  sugar  and  the  indigo  cultures  on  the  public 
health. 

15.  Relation  of  Disease  Germs  to  the  Origin  and  Spread  of  Contagious  and 
Infectious  Diseases , and  to  Endemic  and  Epidemic  Diseases. 

(a)  Relations  of  malaria  to  the  public  health. 

(h)  Nature  of  the  malarial  poison. 

(c)  Physical,  chemical  and  microscopical  characters  of  the  poisons  or  causes  of  the 

following  diseases 

Yellow  fever,  Relapsing  fever, 

Typhoid  fever,  Erysipelas, 

Typhus  fever,  Syphilis, 

Measles,  Phthisis, 

(d)  Relations  of  phthisis  to  the  public  health. 

(e)  Relations  of  syphilis  to  the  public  health. 

(/)  Measures  for  the  arrest  of  smallpox. 

(g)  Value  of  cowpox  inoculation  (vaccination). 

(h)  Accidents  attending  vaccination  ; transmission  of  the  syphilitic  virus  through 

the  medium  of  the  vaccine  virus. 

Smallpox  and  Vaccination. — If  the  great  work  of  public  and  international 
hygiene  be  the  preservation  of  the  human  race  from  disease,  then  to  the  immortal 
Jenner  be  awarded  the  highest  place  in  this  branch  of  human  knowledge. 

Before  the  discovery  of  the  protective  power  of  cowpox  by  Edward  J enner,  one 
in  fourteen  of  all  persons  born  died  of  smallpox,  even  after  inoculation  had  been 
introduced ; and  of  persons  of  all  ages  taken  ill  of  the  smallpox  in  the  natural  way, 
one  in  four  or  six  died ; and  in  addition  to  this  frightful  mortality,  alike  observable 
in  all  the  different  regions  of  the  globe,  many  of  those  who  recovered  were  perma- 
nently disfigured  or  deprived  of  sight,  or  left  with  shattered  constitutions,  the  prey 
to  pulmonary  consumption,  chronic  ophthalmia  and  scrofula. 

Before  the  introduction  of  vaccination,  smallpox  was  infinitely  more  destructive 
to  human  life  than  the  plague  itself ; it  has  swept  away  whole  tribes  of  savage  and 
half-civilized  people,  and  its  miserable  victims  have  been  abandoned  by  their  nearest 
relatives  and  friends  as  persons  destined  by  divine  wrath  to  irrevocable  death.  It 
was  calculated  that  210,000  fell  victims  to  it  annually  in  Europe,  and  that  not  less 
than  15,000,000  of  human  beings  were  destroyed  by  smallpox  every  twenty-five 
years,  that  is,  600,000  annually;  and  the  loathsome  disease  was  not  only  universal 
in  its  ravages,  but  was  so  subtle  in  its  influence  and  insidious  in  its  attack  that  all 
efforts  to  stay  its  violence  or  to  prevent  its  approach  were  futile. 

Even  inoculation , while  it  was  far  less  severe,  violent  and  fatal  than  the  natural 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


315 


smallpox,  tended,  nevertheless,  to  increase  the  spread  of  the  disease,  and  the  exten- 
sive adoption  of  inoculation  was  attended  by  a most  marked  increase  of  smallpox  in 
the  human  race. 

By  the  unaided  efforts  of  a man,  emulous  not  of  distinction,  but  desirous  of 
advancing  truth  and  promoting  the  happiness  and  well-being  of  his  fellow-creatures, 
and  distinguished  as  much  for  his  humility,  long-suffering  and  perseverance,  as  for 
his  unsurpassed  powers  of  practical  observation,  the  world  has  been  furnished  with 
the  means  of  completely  eradicating  this  terrible  scourge,  by  substituting  the  same 
disease  in  a mild,  modified  form,  non-communicable  by  effluvia,  and  capable  of 
effecting  complete  immuuity  from  the  smallpox. 

If  the  medical  profession  had  uniformly  adhered  to  the  advice  and  to  the  rules 
established  by  Jenner,  the  human  race  would  have  been  spared  the  vast  majority  of 
those  unfortunate  accidents  which  tend  to  bring  into  disrepute  the  only  safeguard 
against  smallpox. 

During  the  recent  American  civil  war,  the  investigation  of  the  causes  of  the 
various  deviations  of  the  vaccine  disease  from  its  normal  course,  as  well  as  the  danger 
of  the  introduction  of  other  diseases  into  the  organism — as  syphilis — by  vaccination, 
engaged  the  earnest  attention  of  the  speaker. 

After  an  extended  series  of  investigations,  the  accidents  following  vaccination 
were  referred  to  the  following  causes  : — 

(1)  Modification,  alteration  and  degeneration  of  the  vaccine  vesicle,  dependent 
upon  depressed  and  deranged  forces,  resulting  from  fatigue,  exposure  and  poor  diet, 
and  upon  an  impoverished,  vitiated  and  scorbutic  condition  of  the  blood  of  the  patient 
vaccinated  and  yielding  vaccine  matter. 

In  scorbutic  patients,  all  injuries  of  the  skin  tend  to  form  ulcers  of  an  unhealthy, 
sluggish,  spreading  character. 

(2)  The  employment  of  matter  from  pustules  or  ulcers  which  had  deviated  from 
the  regular  and  normal  course  of  development  in  the  vaccine  vesicle,  such  deviation 
or  imperfection  in  the  vaccine  disease  and  pustule  being  due  mainly  to  previous 
vaccination,  and  the  existence  of  some  eruptive  disease  at  the  time  of  vaccination  ; 
or,  in  other  words,  the  employment  of  matter  from  patients  who  had  been  previously 
vaccinated,  and  who  were  partially  protected,  or  who  were  affected  with  some  skin 
disease  at  the  time  of  the  insertion  of  the  vaccine  virus. 

(3)  Dried  vaccine  lymph  or  scabs,  in  which  decomposition  had  been  excited  by 
carrying  the  matter  about  the  person  for  a length  of  time,  and  thus  subjecting  it  to 
a warm,  moist  atmosphere. 

(4)  The  mingling  of  the  vaccine  virus  with  that  of  the  smallpox  matter  taken 
from  those  who  were  vaccinated  while  they  were  laboring  under  the  action  of  the 
poison  of  smallpox,  was  capable  of  producing  a modified  variola  and  comparatively 
mild  disease  in  the  inoculated,  and  which  was  capable  of  communicating,  by  effluvia, 
smallpox  of  the  worst  character  to  the  unprotected. 

(5)  Dried  lymph  or  vaccine  scabs  from  patients  who  had  suffered  with  erysipelas 
during  the  process  of  the  vaccine  disease,  or  whose  systems  were  in  a depressed  state 
from  imperfect  food,  impure  ventilation  and  the  exhalations  from  typhoid  fever, 
erysipelas,  hospital  gangrene,  pyaemia  and  offensive,  suppurating  wounds. 

(6)  Fresh  and  dried  vaccine  lymph  or  scabs  from  patients  suffering  with  secondary 
or  constitutional  syphilis  at  the  time  of  vaccination  and  during  the  progress  of  the 
vaccine  disease — vaccino-syphilis. 

The  subject  of  vaccination,  and  the  continued  renewal  of  the  vaccine  virus  in  its 


I 


316  NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 

original  purity  and  potency,  is  of  vast  importance  to  the  human  race,  and  should 
command  not  merely  national,  but  international  investigation  and  action. 

There  should  be  established  in  each  nation  and  kept  in  perfect  working  order 
and  in  perpetual  action — 

(1)  A medical  commission  composed  of  three  or  more  competent  medical  men,  of 
undoubted  integrity  and  capacity  for  observation  and  scientific  investigation,  who 
shall  be  charged  with  the  preservation  and  distribution  of  pure  vaccine  and  cow-pox 
virus.  Every  spontaneous  outbreak  of  cow-pox  should  be  carefully  observed,  recorded 
and  reported  for  the  information  and  use  of  the  medical  profession. 

(2)  Cow-pox  or  vaccine  farms  for  the  propagation  and  preservation  of  the  cow-pox. 

(3)  An  international  commission  composed  of  not  less  than  twelve  learned,  com- 
petent and  trustworthy  medical  men,  skilled  in  the  modern  methods  of  chemical, 
microscopic,  physiological  and  pathological  research,  whose  duty  it  shall  be  to  observe 
and  report,  at  stated  intervals,  the  progress  of  smallpox  in  the  various  nations 
of  the  earth.  All  matters  touching  the  relations  of  smallpox  to  other  dis- 
eases, and  of  vaccinia  and  cow-pox  to  allied  diseases  and  to  syphilis,  as  well  as  all 
deteriorations  of  the  vaccine  virus,  should  be  carefully  investigated  by  this  com- 
mission. 

(i)  Value  of  inoculation  or  vaccination  of  healthy  persons  exposed  to  the  yellow 
fever  atmosphere  in  preventing  or  modifying  this  disease. 

O’)  Relative  value  of  employing  the  virus,  microbe  or  cultivated  and  attenuated 
virus  of  yellow  fever. 

Cordial  invitations  have  been  extended  by  the  President  of  the  XVth  Section, 
Public  and  International  Hygiene,  Ninth  International  Medical  Congress,  to  Dr. 
Domingos  Freire,  of  Rio  de  Janeiro,  Brazil,  and  Dr.  Manuel  Carmona  y Valle,  of 
the  city  of  Mexico,  not  only  to  occupy  the  positions  of  Vice-Presidents  of  the  Section 
on  Public  and  International  Hygiene,  but  also  to  demonstrate  their  methods  of 
yellow  fever  inoculation  before  its  officers  and  members  of  council. 

I have  received  assurances  that  these  distinguished  physicians  will  be  present,  and 
give  full  demonstrations  and  explanations  of  the  nature  of  the  microbe  of  yellow 
fever  and  of  their  method  of  inoculation  against  this  disease. 

The  cause  of  science  demands  that  these  questions  should  not  be  disposed  of'  by 
the  criticisms  and  lucubrations  of  theorists  ; the  profession  demands  demonstration. 

A feeble  effort  has  recently  been  made  by  the  United  States  to  investigate,  by 
means  of  one  or  more  experts,  the  method  of  inoculation  against  yellow  fever  per- 
formed by  Professor  Freire  in  Brazil ; but  whatever  the  results  of  the  expedition 
may  be,  the  sum  appropriated  by  Congress  for  the  work  was  insignificant. 

The  confusion  and  uproar  arising  in  the  public  mind,  and  the  reliance  of  the 
populace,  in  epidemics  of  yellow  fever,  upon  the  ‘ ‘ shot-gun’  ’ quarantines  of  barbarism 
and  brute  force,  as  manifested  in  the  occurrences  in  and  around  Biloxi,  Mississippi, 
in  1886,  would  indicate  that  the  American  mind  is  not  yet  ready  for  the  trial  of 
inoculation  against  yellow  fever. 

(Jc)  Value  of  inoculation  against  Asiatic  cholera,  charbon  and  other  diseases. 

( l ) Value  of  inoculation  with  attenuated  virus  from  the  spinal  cord  of  animals 
suffering  with  hydrophobia,  for  the  modification  or  prevention  of  tins 
disease. 

The  President  of  the  XVth  Section,  Public  and  International  Hygiene,  addressed 
an  earnest  request  to  M.  Pasteur,  of  Paris,  to  preside  as  a Vice-President  in  tins 
Section,  and  to  demonstrate  to  the  medical  profession  the  great  and  remarkable  dis- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  317 


covcries  which  have  thus  for  crowned  his  labors  with  reference  to  charbon  and 
hydrophobia.  The  distinguished  investigator  has  declined,  on  account  of  ill  health, 
from  overwork. 

M.  Pasteur,  in  his  investigations  on  hydrophobia,  claims  that  he  has  established 
the  following: — 

(1)  M.  Pasteur  has  discovered  a method  of  protection  from  rabies,  which  may  be 
compared  with  that  which  vaccination  affords  against  smallpox. 

(2)  M.  Pasteur  has  discovered  a treatment  capable  of  preventing  the  development 
of  the  disease  in  persons  bitten  by  rabid  dogs. 

(3)  M.  Pasteur  has  shown  that  the  virus  of  hydrophobia  is  located  in  the  medulla 
and  spinal  cord  of  the  affected  animal ; that  inoculation  of  this  virus  in  healthy 
animals  is,  as  well  as  the  bite  of  rabid  animals,  capable  of  producing  the  disease,  the 
only  difference  being  that  in  the  former  case  the  stage  of  inoculation  is  shorter. 

(4)  The  virus  located  in  the  medulla  and  spinal  cord  is  attenuated  by  exposure 
of  the  organs  in  dry  air,  and  inoculation  with  this  attenuated  virus  is  capable  of  pre- 
venting the  development  of  hydrophobia,  provided  this  protective  inoculation  be 
begun  during  the  period  of  incubation. 

In  this  connection,  it  is  worthy  of  note  that  in  the  early  history  of  vaccination 
protective  powers  against  certain  diseases  were  attributed  to  cow-pox  inoculation. 

Soon  after  the  world  was  informed  that  the  vaccine  poison  was  preventive  of  the 
smallpox,  a disposition  was  shown  by  physicians  and  speculative  men  to  extend  its 
influence  and  prophylactic  powers  to  other  diseases.  The  idea  was  advanced  that  the 
morbid  action  excited  by  the  virus  from  the  cow  could  as  well  prevent  other  con- 
tagious distempers  as  that  one  for  which  it  was  particularly  employed  ; and  if  it  was 
capable  of  doing  such  good  in  the  human  constitution,  it  would  be  no  less  operative 
in  the  bodies  of  brutes.  Accordingly,  it  was  said  that  the  plague  of  Syria  could  be 
prevented  by  previous  vaccination,  but  Mr.  V alii,  who  made  the  experiment  on  him- 
self, was  afterward  seized  with  the  plague. 

This  alleged  power  of  vaccination  in  controlling  the  plague  attracted,  at  an  early 
period,  a considerable  degree  of  attention,  and  Dr.  Jenner  received  letters  on  this 
subject  from  many  quarters.  The  circumstances  having  been  made  known  to  the 
Spanish  Consul  at  Morocco,  a communication  was  transmitted  to  Sir  Joseph  Banks 
on  that  subject,  and  from  him  to  Jenner. 

The  opinion  of  Jenner  on  this  point  was  thus  expressed  : — 

“ I never  was  so  sanguine  in  my  hopes  of  seeing  the  plague  extinguished  by 
vaccine  inoculation  as  some  of  my  friends  were,  as  you  may  have  seen  from  a few 
introductory  lines  which  Dr.  Carre  cites  in  the  public  papers.  I will  just  drop  a hint; 
the  vaccine  disease,  in  my  opinion,  is  not  a preventive  of  the  smallpox,  but  the 
smallpox  itself ; that  is,  the  horrible  form  under  which  it  appears  in  its  contagious 
state  is  (as  I conceive)  a malignant  variety.  Now,  if  it  should  ever  be  discovered 
that  the  plague  is  a variety  of  some  milder  disease,  generated  in  a way  that  may 
even  elude  our  researches,  and  the  source  should  be  discovered  whence  it  sprang,  this 
may  be  applied  to  a great  and  grand  purpose.  The  phenomena  of  the  cow-pox  open 
many  paths  for  special  action,  every  one  of  which  I hope  may  be  explored.” 

The  prophetic  hope  of  Jenner , breathed  more  than  half  a century  ago , is  being 
realized  in  our  day  by  the  investigations  of  Pasteur , Koch  and  others. 

Dr.  Jenner  proposed  vaccination  against  hydrophobia.  Thus,  in  a letter  to  Rev. 
Dr.  Worthington,  dated  London,  Flading’s  Hotel,  Oxford  Street,  1811,  he  says: 
“ Yesterday  I dined  with  Professor  Davy.  I wish  you  had  been  with  us.  His  mind 
is  all  in  a blaze.  He  seems  to  be  one  of  those  rare  productions  which  nature  allows 
us  to  see  in  a score  of  centuries.  He  touched  on  hydrophobia.  He  started  au 


318 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ingenious  idea,  that  of  counteracting  the  effect  of  one  morbid  poison  with  another. 
What  think  you  of  a viper  ? Not  its  broth  but  its  fangs,  as  soon  as  the  first  symp- 
tom of  the  disease  appears,  from  canination.  If  this  should  succeed,  we  must 
domiciliate  vipers,  as  we  have  leeches.  But  from  this  hint  I should  be  disposed  to 
try,  under  such  an  event,  vaccination  ; as  it  can  almost  always  be  made  to  act  quickly 
on  the  system,  whether  a person  has  previously  felt  its  influence  or  not,  or  that  of 
smallpox.”  John  Archer,  M.D.,  of  Harford  County,  Maryland,  had  previously,  in 
1808,  recommended  vaccination  for  the  arrest  of  pertussis. 

Establishment  of  National  Laboratories  for  the  Chemical  and  Microscopical 
Investigation  of  the  Causes  and  Prevention  of  Endemic  and  Epidemic  Diseases. 
— Laboratories  for  the  thorough  and  continuous  investigation  of  the  causes  and 
pathology  and  modes  of  modification,  prevention  and  arrest  of  such  diseases  as 
smallpox,  yellow  fever,  Oriental  plague,  Oriental  leprosy,  typhoid  fever,  typhus  and 
malarial  fever,  should  be  established  and  maintained  by  national  aid  in  all  the  im- 
portant centres  of  population. 

In  the  United  States,  laboratories  for  the  thorough  microscopical  and  chemical 
investigation  of  disease,  and  for  the  performance  of  carefully  devised  physiological 
and  pathological  experiments,  should  be  established  and  maintained  by  law,  in  Boston, 
New  York,  Philadelphia,  Washington,  D.  C.,  Baltimore,  Charleston,  S.  C.,  New 
Orleans,  Louisiana,  Cincinnati,  Chicago,  St.  Louis  and  San  Francisco. 

If  the  discoveries  of  Pasteur  with  reference  to  charbon  and  hydrophobia,  and  of 
other  observers  with  reference  to  phthisis  and  yellow  fever,  are  to  be  utilized  in  a uni- 
form and  scientific  manner  for  the  prevention  of  disease  by  the  inoculation  of 
altered,  attenuated  or  modified  virus,  such  results  must  be  accomplished  through  the 
medium  of  well-endowed  and  perpetually  active  laboratories,  under  the  direction  of 
learned  and  expert  observers  and  well-trained  and  skillful  experimenters. 

16.  Structure , Hygienic  Arrangements  and  Sanitary  Conduct  of  Hospitals. 

(a)  Structure,  ventilation,  disinfection  and  conduct  of  hospitals  for  the  treatment 

of  infectious  and  contagious  diseases. 

( b ) Smallpox  hospitals. 

(c)  Yellow  fever  hospitals. 

(d)  Cholera  hospitals. 

(e)  Hospitals  for  the  isolation  and  care  of  Oriental  leprosy. 

Unless  hospitals  devoted  to  the  treatment  and  isolation  of  contagious  and  infec- 
tious diseases  be  properly  located,  guarded  and  disinfected,  they  become  dangerous 
mediums  for  the  propagation  and  spread  of  contagion. 

In  the  case  of  smallpox,  vaccination  furnishes  a ready  method  of  preventing  the 
spread  to  the  patients,  operatives  and  nurses;  but,  unless  the  most  stringent  measures 
be  taken,  of  cleanliness  and  disinfection,  the  disease  will  spread  beyond  the  limits  of 
the  pest-house. 

The  foul  air  of  the  hospital  should  be  so  arranged  as  to  pass  upward  through 
openings  supplied  with  burning  gas  jets  or  the  electric  light,  so  that  the  contagious 
organic  matters  may  be  destroyed.  All  infected  clothing  and  bedding  should  be 
either  destroyed  by  fire  or  else  subjected  to  the  action  of  boiling  water  and  superheated 
steam.  Heat  applied  through  the  medium  of  boiling  water  and  steam  has  been  found 
by  practical  sanitarians  the  most  efficient  and  easily  applied  of  all  disinfecting  agents, 
and  possesses  the  advantage,  also,  of  purifying,  coagulating  and  washing  away  the 
contagious  organic  matters.  Solutions  of  carbolic  acid  (five  per  cent.),  of  corrosive 
sublimate  (one  per  cent,  and  less),  as  well  as  other  antiseptics  and  disinfectants,  may 
be  employed.  For  the  purification  of  the  air  of  wards  and  of  sick  rooms  and  dead 
houses,  burning  sulphur  furnishes  in  sulphurous  anhydride  the  most  effective  disin- 


SECTION  XV — rUBLIC  AND  INTERNATIONAL  HYGIENE.  319 


fectant  and  antiseptic.  As  contagious  diseases  are  propagated  by  particulate  conta- 
gious particles , their  removal  from  any  given  space  or  from  porous  materials  is  best 
accomplished  by  such  gaseous  bodies  as  sulphurous  anhydride  and  chlorine.  If  the 
attempt  is  made  to  disinfect  any  given  space  by  subjecting  it  to  the  fumes  of  heated 
corrosive  sublimate  (bichloride  of  mercury),  it  will  be  found  that  the  particles  of  cor- 
rosive sublimate,  volatilized  by  heat,  quickly  congeal  and  fall  as  a fine  powder  in  the 
immediate  vicinity  of  the  source  of  heat. 

From  practical  experience,  it  is  found  that  fumigation  with  sulphurous  anhydride 
and  washing  the  walls,  floor  and  furniture  with  a one  per  cent,  solution  of  corrosive 
sublimate  or  a five  per  cent,  of  carbolic  acid,  and  then  whitewashing  the  walls  with 
lime,  are  sufficient  to  eradicate  the  poisons  of  smallpox,  yellow  fever,  Asiatic  cholera, 
and  of  other  contagious  and  infectious  diseases. 

It  is  essential  that  hospitals  should  be  furnished  with  educated,  well-fed,  healthy 
and  properly  paid  nurses. 

The  plan  adopted  in  the  Charity  Hospital  of  New  Orleans  and  in  other  hospitals, 
of  employing  the  convalescents,  without  pay,  to  nurse  their  sick  companions,  cannot 
be  too  strongly  condemned. 

No  matter  how  clean  and  pleasant  the  wards  of  a hospital  may  appear,  if  the 
system  of  alimentation  and  nursing  be  defective,  the  results  of  medical  and  surgical 
treatment  must  necessarily  be  unsatisfactory. 

17.  Measures  for  the  Arrest  of  Contagious  and  Infectious  Diseases. 

(a)  Measures  for  the  arrest  of  smallpox.  Yaccination  and  revaccination. 

It  is  possible  to  prevent  the  spread  of  smallpox  by  the  prompt  vaccination  of  all 
persons  exposed  to  this  contagion,  as  I have  repeatedly  demonstrated  in  New  Orleans, 
and  upon  shipboard  at  the  Mississippi  Quarantine  station,  during  my  term  of  ser- 
vice as  President  of  the  Board  of  Health  of  the  State  of  Louisiana,  1880-1884. 

All  houses  occupied  by  smallpox  patients  should  be  thoroughly  disinfected. 

( b ) Measures  for  the  arrest  of  yellow  fever. 

(1)  The  exclusion  of  passengers  from  the  infected  ports  of  Central,  South  and 
Insular  America  during  those  periods  of  the  year  in  which  this  disease  is  liable  to 
make  a lodgment  in  the  seaport  cities  of  the  United  States. 

(2)  The  conduct  of  the  commerce  with  infected  ports,  as  Yera  Cruz,  Havana  and 
Rio  de  J aneiro,  by  means  of  acclimated  crews. 

(3)  The  fumigation  of  the  ship  and  cargo  at  the  point  of  departure. 

(4)  Rigid  quarantine,  including  careful  inspection  and  thorough  cleansing  and 
disinfection  of  all  ships  and  their  cargoes  from  infected  ports. 

(5)  In  the  event  of  the  appearance  of  a case  of  yellow  fever  on  shipboard  in  the 
harbor  of  New  Orleans,  or  of  any  other  city,  the  immediate  isolation  of  the  ship  and 
crew,  and  their  return  to  the  quarantine  station.  The  prompt  execution  of  such  mea- 
sures in  1880,  in  the  case  of  the  bark  Excelsior,  preserved  the  city  of  New  Orleans, 
and  probably  the  Mississippi  Yalley,  from  an  epidemic  of  yellow  fever. 

(6)  When  a case  of  yellow  fever  occurs  in  a town  or  city,  it  should  immediately 
be  isolated,  and  if  practicable  transferred  to  a hospital  devoted  especially  to  the  treat- 
ment of  this  disease.  The  immediate  premises  as  well  as  the  surrounding  blocks, 
covering  an  area  the  diameter  of  which  shall  not  be  less  than  1500  feet,  or  in  small 
places  the  entire  village,  to  be  thoroughly  cleansed  and  disinfected.  The  buildings 
must  be  systematically  fumigated  with  burning  sulphur  (sulphurous  anhydride)  as 
far  as  practicable;  all  woodwork  whitewashed  ; all  foul  drains  and  alleys  disinfected 
with  carbolic  acid,  copperas  and  solutions  of  mercuric  chloride.  All  privies  disinfected 
with  solutions  of  copperas  and  carbolic  acid,  and  mercuric  chloride. 


320 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


(7)  In  the  event  of  death,  the  bedding  and  bed-clothing  and  soiled  clothing  of  the 
deceased  should  be  promptly  burned  in  a properly  constructed  stove.  The  body 
should  be  wrapped  in  cloth  saturated  with  solutions  of  carbolic  acid  and  bichloride 
and  transferred  to  the  coffin  and  buried  at  the  earliest  practicable  moment.  All 
gatherings  around  the  corpse  should  be  prohibited. 

By  such  measures  the  yellow  fever  was  arrested  in  New  Orleans  in  1882;  the  first 
case  (Henry  Forbes)  occurring  as  early  as  June  25th,  only  three  other  cases  of  yellow 
fever  were  reported  during  the  remainder  of  this  season. 

(8)  All  excreta,  in  smallpox,  yellow  fever  and  Asiatic  cholera,  should  be  promptly 
and  thoroughly  disinfected  and  destroyed. 

III.  INTERNATIONAL  HYGIENE. 

International  hygiene  is  based  on  public  and  national  hygiene,  and  differs  in  scope 
rather  than  in  any  essential  differences,  and  it  must  be  admitted  that  our  divisions  of 
this  subject  are,  to  a certain  extent,  arbitrary. 

Thus  we  have  placed  under  this  division,  International  Hygiene,  the  consid- 
eration of  those  subjects  which  should  be  regarded  of  prime  importance  to  each  and 
every  nation  in  times  of  health,  and  in  periods  of  pestilential  invasion,  in  peace  and 
in  war. 

At  the  present  day  the  great  nations  of  Europe  are  in  a strained  and  artificial 
condition.  One-half  the  fighting  males  are  standing  guard,  fully  armed,  carefully 
watching  their  antagonists,  and  ready  on  a moment’s  warning  to  engage  in  battle. 
It  would  be  needless  for  us  to  inquire  whether  this  armed  state  and  this  withdrawal 
of  the  energies  of  the  young  men  from  the  productive  capital  of  mankind  is  best  for 
the  advancement  of  civilization,  and  whether  it  be  necessary  thus  to  bind  down  the 
explosive  forces  of  the  race;  we  must  deal  with  things  as  they  exist,  and  endeavor  to 
form  a correct  estimate  of  this  new  branch  of  knowledge  which  relates  to  the  preserva- 
tion of  the  national  forces  in  the  highest  degree  of  health  and  efficiency. 

The  most  important  subjects  of  International  Hygiene  which  are  of  paramount 
interest  to  all  civilized  nations  are  : — 

1.  Militarjj  hygiene. 

2.  Naval  hygiene. 

3.  Quarantine. 

1.  Military  hygiene. 

(a)  Food  of  the  soldier. 

(b)  Clothing  of  the  soldier. 

(c)  Exercise  and  rest;  effect  of  infantry,  cavalry,  artillery  and  bicycle  exercise  on 

the  soldier. 

( d ) Shelter — barracks,  their  structure,  location  and  ventilation;  tents,  their 

structure. 

(e)  Water  supply  of  armies;  method  of  testing  and  improving;  injurious  effects 

of  stagnant  water,  of  marshes,  swamps  and  rice  fields,  on  armies. 

(/)  Military  prisons  and  military  prisoners. 

(g)  The  establishment  of  uniform  rules,  to  be  recognized  by  all  civilized  nations, 

for  the  treatment,  food  and  clothing  of  military  prisoners,  and  for  the 

regular  and  continuous  exchange  of  all  military  prisoners. 

If  one-half  the  male  fighting  population  of  the  great  nations  of  Europe  be  always 
subject  to  military  orders  and  to  rapid  mobilization,  it  is  evident  that  the  science  of 
military  hygiene  should  take  rank  as  of  the  greatest  interest  and  importance  to  man- 
kind. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  321 


It  lias  been  sought  to  make  this  an  addendum  to  medicine  and  surgery. 

The  amputating  knife,  saw,  trephine,  antiseptic  bandage,  opium,  chloroform,  qui- 
nine and  calomel  are  all  most  valuable  when  the  men  are  wounded  and  sick;  but  the 
enlightened  military  surgeon  of  this  age  conceives  it  to  be  his  highest  duty  to  remove 
every  preventable  cause  of  disease,  and  to  preserve  the  health  and  vigor  of  the  men 
entrusted  to  his  care  by  the  rigid  execution  of  hygienic  laws,  not  merely  by  the  selec- 
tion of  the  site  of  the  camp  and  the  enforcement  of  sanitary  legislation,  but  by  atten- 
tion to  the  food,  water,  clothing  and  exercise  of  the  soldiers. 

The  grand  work  of  the  military  surgeon  should  be  to  prevent  disease,  and  preserve 
his  command  in  the  highest  degree  of  strength. 

The  value  of  hygienic  measures  and  the  destructive  effects  of  disease  were  clearly 
shown  in  the  American  war  of  1861-65,  when  the  casualties  of  battle  were  exceeded 
fourfold  by  the  deaths  caused  by  diseases,  the  most  important  and  fatal  of  which 
were  pneumonia,  typhoid  fever,  diarrhoea  and  dysentery. 

During  this  war  the  gigantic  mass  of  suffering,  disease  and  death  engendered 
among  the  unfortunate,  dejected  and  hopeless  captives  in  the  military  prisons  of  the 
North  and  South,  rendered  it  evident  that  the  hygiene  of  military  prisons  and  mili- 
tary prisoners  had  received  no  practical  recognition. 

It  was  also  shown  that  the  stronger  power  was  capable  of  finally  overthrowing  the 
weaker  by  retaining  all  prisoners  of  war  in  an  indefinite  captivity  by  practically  discon- 
tinuing all  exchanges. 

Definite  rules  for  the  guidance  of  military  prisoners  and  prisons,  and  for  the  con- 
tinuous exchange  of  prisoners  of  war  during  periods  of  war,  should  be  formulated 
and  adopted  by  the  representatives  of  those  civilized  nations  who  may  be  willing  to 
accord  to  this  class  of  the  unfortunate  victims  of  the  accidents  of  war  the  essential 
conditions  of  the  preservation  of  health  and  life. 

2.  Naval  Hygiene. — By  naval  hygiene  we  mean  to  include  all  that  relates  to 
maritime  life,  whether  relating  to  commerce  or  war.  All  maritime  nations  arc  inter- 
ested in  the  construction  of  vessels,  so  as  to  secure  strength,  swiftness,  capacity,  sea- 
worthiness and  freedom  from  all  preventable  causes  of  disease.  Naval  hygiene, 
although  relating  chiefly  to  the  sanitary  condition  of  ships,  seamen  and  naval  estab- 
i lishments,  illustrates  to  a marked  degree  the  general  results  of  the  doctrine  of  the 
prevention  of  disease.  Such  demonstration  of  the  prevention  and  arrest  of  disease 
by  hygienic  measures  is  especially  adapted  to  the  isolated  community  of  the  ship. 
It  is  possible  at  the  present  day  to  preserve  the  crews  of  ships  from  cholera  and 
yellow  fever  when  lying  in  harbors  where  these  diseases  are  prevailing,  and  to  arrest 
the  effects  of  the  deadly  malaria  of  the  African  coast,  by  hygienic  and  prophylactic 
measures.  Scurvy,  ship  fever  and  malignant  dysentery,  which  formerly  decimated 
r crews,  now  only  occur  as  the  result  of  sanitary  neglect. 

It  is  now  recognized  that  the  true  duty  of  the  naval  officer  is  to  preserve  the  men 
confided  to  his  care  in  the  highest  state  of  health,  and  the  most  effective  mode  of 
banishing  infectious  and  contagious  diseases  from  the  high  seas  is  to  establish  uni- 
versal sanitary  rules  and  regulations  for  the  guidance  of  the  merchant  marine  as  well 
as  vessels  of  war.  The  poor  emigrant  and  wealthy  passenger,  the  common  sailor  and 
marine,  as  well  as  the  highest  civil  and  military  officer,  should  all  alike  be  subject  to 
the  inexorable  rules  of  naval  hygiene. 

Even  with  our  best  exertions  it  must  be  admitted  that  it  is  difficult,  if  not  impos- 
sible, to  make  the  ship  as  comfortable  and  as  healthy  as  the  home  on  shore.  The 
' ship  is  practically  a floating  box,  sealed  against  the  admission  of  water,  and  neces- 
sarily also  to  the  admission  of  air,  except  in  a few  places  above  the  water  line.  At/ 

Vol.  IV— 21 


322 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


sea,  and  especially  in  stormy  weather,  many  of  the  openings  for  air  have  to  be  closed. 
The  subject  of  ventilation,  therefore,  has  been  one  of  the  most  important  problems 
in  naval  hygiene. 

The  air  space  on  shipboard  being  necessarily  limited,  the  average  per  individual 
can  only  be  indirectly  increased  by  reducing  the  crew  to  the  smallest  possible  number 
of  effective  men,  by  distributing  them  as  equally  as  may  be,  and  by  removing  all  but 
absolutely  indispensable  impediments. 

When  such  diseases  as  typhus  fever,  smallpox  or  yellow  fever  break  out  on  board 
an  emigrant  ship,  military  transports  or  men-of-war,  the  conditions  are  more  serious 
than  in  the  most  crowded  city. 

Naval  hygiene  should  embrace  the  following  considerations  and  subjects  of  inquiry 
and  discussion : — 

(а)  The  structure  of  the  ship  ; materials  used — wood,  iron  or  steel ; size  of  ship ; 

arrangement  of  cabins,  compartments,  decks,  bulkheads,  sleeping  apart- 
ments, forecastle,  latrines,  hold,  machinery,  etc. 

(б)  Ventilation  of  the  ship;  discussion  of  the  best  methods  of  ventilating  the 

various  compartments  of  the  ship. 

(c)  Cleansing  of  the  ship. 

Moisture  must  be  regarded  as  the  most  potent  cause  of  disease  in  .ships,  and 
frequent  ablutions  of  the  decks  and  sides  with  water  are  to  be  condemned,  and  should 
be  replace  by  large  volumes  of  dry  air,  introduced  by  steam  fans  to  all  parts  of  the 
ship.  Thorough  ventilation  of  all  parts  of  the  ship  at  all  times,  by  means  of  strong, 
well-constructed  steam  fans,  should  be  urged  as  of  the  highest  value  for  the  preser- 
vation of  the  health  of  crew  and  passengers. 

{d)  Arrangement  of  the  cabins,  sleeping  apartments,  hospitals  and  store  rooms, 
so  as  to  secure  the  greatest  air  space  and  the  freest  ventilation. 

( e ) Treatment  of  the  sick  on  shipboard. 

Whenever  practicable,  the  sick  should  at  the  earliest  possible  moment  be  removed 
to  the  marine  hospital  on  shore. 

(/)  W ater  supply. 

iff)  Food. 

( h ) Clothing. 

(i)  Conduct  of  officers,  crew  and  passengers  on  shipboard,  on  the  voyage  and  in  port. 

When  visiting  ports  in  which  infectious  and  contagious  diseases  are  prevailing, 

the  vessel  should  anchor  at  least  one  thousand  feet  from  the  shore,  and  the  crew  and 
passengers  should  not  be  allowed  to  visit  infected  localities  or  to  remain  on  shore  at 
night.  While  lying  in  harbors  and  rivers  surrounded  by  extensive  marshes  and 
swamps,  as  on  the  coast  of  Africa  and  of  the  Southern  States,  three  grains  of  the 
sulphate  of  quinia,  in  a glass  of  sherry,  or  port  wine,  or  water,  should  be  administered 
daily  to  each  passenger  and  member  of  the  crew. 

(j)  The  appointment  by  each  government  of  a reliable,  practical  representative 

in  the  various  commercial  ports  of  the  world,  whose  duty  it  shall  be  to 
superintend  the  sanitary  condition  of  every  ship  and  crew,  and  the  loading 
of  cargoes  and  the  issuance  of  correct  bills  of  health. 

The  following  measures  should  be  instituted  in  each  important  port  subject  to 
infectious  and  contagious  diseases  : — 

(1)  Thorough  inspection  of  the  ship  and  cargo. 

(2)  When  yellow  fever,  cholera  or  smallpox  are  prevalent,  the  thorough  fumigation 
of  the  ship  and  cargo  should  be  conducted ; also  cleansing  of  hold,  deck  and  latrines, 
forecastle,  cabins  and  berths,  with  solutions  of  four  per  cent,  carbolic  acid  and  one 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  323 


per  cent,  solution  or  less  of  bichloride  of  mercury.  The  ordinary  solution  of  one  of 
the  mercuric  chloride  to  one  thousand  of  water  is  practically  of  little  value  for  the 
destruction  of  diseased  germs  and  the  thorough  disinfection  of  bilge  water.  The 
bichloride  of  mercury  is  immediately  decomposed,  and  the  metallic  mercury  and 
mercuric  oxide  precipitated  by  all  metals  and  by  alkalies  and  lime  rock  in  ballast. 

(3)  Subjection  of  all  articles  of  clothing  or  merchandise  which  may  have  come  in 
contact  with  the  poisons  of  Asiatic  cholera  or  yellow  fever  to  the  disinfectant  action 
of  heat  (hot  air  and  steam),  in  properly  constructed  apparatus,  so  constructed  as  to 
allow  of  a continuous  current  of  hot  air  through  the  chambers. 

(4)  Careful  inspection  of  officers,  crew  and  passengers,  and  the  exclusion  of  all 
individuals  who  may  be  suspected  of  having  been  exposed  to  infection. 

(5)  The  bill  of  health  issued  by  the  medical  officer  to  the  ship  should  give  the 
mortality  and  prevailing  diseases  of  the  port  for  at  least  thirty  days,  and  also  a full 
and  accurate  detail  of  the  sanitary  condition  of  the  ship,  crew  and  passengers  and 
cargo.  A thorough  system  of  inspection  thus  executed  would  do  much  to  prevent 
the  spread  of  contagious  and  infectious  diseases,  and  also  to  mitigate  the  hardships 
and  arbitrary  usages  of  quarantine. 

The  advances  made  in  naval  hygiene,  and  the  additions  to  the  appliances  of  the 
sanitarian  for  the  arrest  of  contagious  and  infectious  diseases,  have  been  of  great 
value  during  the  past  century,  and  the  foundation  of  this  important  branch  of  science 
was  laid  by  the  labors  of  such  men  as  Sir  John  Pringle,  1750  (Note  1) ; Stephen 
Hales,  1755  (Note  2) ; John  Huxham,  1757  (Note  3) ; Daniel  McBride,  1764  (Note 
4);  John  Howard,  1789  (Note  5);  Angus  Smith,  1767  (Note  6);  Guyton-Morveau, 
1773  (Note  7);  Carmichael  Smith,  17S5— 1795  (Note  9);  Cruickshank,  1797  (Note 
10) ; and  others  (Note  11).* 

3.  Quarantine. 

(a)  The  history  of  quarantine. 

(b)  Maritime  quarantine. 

(c)  Land  quarantine. 

(d)  Conduct  of  quarantine  stations. 

(e)  Sanitation  of  ships. 

(/)  Sanitation  of  quarantine  ports. 

(g)  Methods  of  eradicating  infectious  and  contagious  diseases  from  infected  ports. 

( h ) Sanitation  of  railroad  stations  and  cars. 

(i)  Land  quarantine;  its  objects,  value  and  mode  of  conduction.  The  proper 

construction,  ventilation  and  conduct  of  railroad  cars,  sleeping  coaches, 
warehouses,  depots,  so  as  to  prevent  the  dissemination  of  contagious  and 
infectious  diseases. 

O')  Methods  of  isolation  and  disinfection  adapted  especially  to  land  travel. 

(k)  Regulation  and  control,  on  sea  and  land,  of  such  diseases  as  yellow  fever, 

Asiatic  cholera,  Oriental  plague,  Oriental  leprosy,  typhus  and  typhoid 
fevers,  smallpox,  scarlatina  and  measles. 

(l)  The  relations  of  the  duration  of  quarantine  as  determined  by  the  natural 

history  of  various  diseases,  or  more  especially  by  the  period  of  the  incu- 
bation of  their  specific  poisons. 

* In  a brief  address,  covering  a vast  number  of  important  subjects,  wo  could  only  allude  to 
the  important  subject  of  the  history  of  Maritime  hygiene  and  the  progress  of  discovery  with 
reference  to  disinfectants  and  disinfection,  and  the  perfection  of  measures  for  the  arrest  of  infec- 
tious and  contagious  diseases.  Wo  have  collected  the  notes,  presenting  the  results  of  our  inves- 
tigations, into  the  form  of  an  Appendix.  (See  p.  330,  et  aeq.) 


324 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


(to)  Value  of  heat  (dry  heat,  steam,  superheated  steam)  iu  the  disinfection  and 
cleansing  of  infected  vessels,  clothing,  houses  and  furniture. 

( n ) Relative  value  of  sulphurous  anhydride  and  other  antiseptics  and  disinfect- 

ants, as  bichloride  of  mercury  (corrosive  sublimate),  carbolic  acid,  ferruginous 
and  plumbic  salts,  chlorine,  bromine  and  iodine,  and  biniodide  of  mercury. 

(o)  Apparatus  for  the  application  of  various  kinds  of  antiseptics,  germicides  and 

disinfectants. 

( p ) Relative  germicidal  and  antiseptic  powers  of  various  disinfectants. 

(q)  Structure  and  conduct  of  quarantine  hospitals. 

( r ) Quarantine  should  embrace  not  merely  detention,  but  also  thorough  disin- 

fection of  ship  and  cargo,  and  thorough  disinfection  and  cleansing  of  all 
wearing  apparel  and  bedding  of  passengers  and  crew  ; and  when  necessary 
the  cargo  should  be  discharged  and  thoroughly  aired  and  disinfected.  The 
ballast  of  infected  ships  should  also  be  carefully  and  thoroughly  disinfected. 

(s)  Quarantine  should  be  effectively  and  intelligently  conducted  so  as  to  impose 

the  least  possible  restrictions  on  commerce  ; at  the  same  time  the  public 
health  should  never  be  sacrificed  to  the  insatiate  and  brutal  greed  of  gain. 

Quarantine  (from  the  Italian,  quarantina , forty)  has  at  the  present  day  lost  its 
ancient  meaning  of  forced  detention  of  ships,  goods  and  passengers  for  forty  days, 
and  may  be  thus  defined. 

Quarantine:  The  enforced  isolation  of  individuals  and  certain  objects,  whether 
coming  by  sea  or  land  from  a place  where  dangerous  communicable  disease  is  pre- 
sumably or  actually  present,  with  a view  of  limiting  the  spread  of  the  malady.  The 
objects  liable  to  quarantine  include,  on  the  assumption  of  their  being  apt  to  carry  the 
contagion  or  infection  of  the  disease,  the  luggage  and  personal  effects  of  the  individ- 
ual isolated,  certain  articles  of  merchandise  and  ships,  and  in  land  quarantine  car- 
riages and  other  vehicles.  Sometimes  entire  communities  and  districts  are  subjected 
to  quarantine.  According  to  systematic  writers  quarantine  had  its  origin  in  the 
Fourteenth  century,  when  the  principle  of  isolation,  applied  from  a much  earlier 
period  to  leprosy,  began  to  be  extended  to  pestilential  diseases,  and  leper  hospitals 
(lazarets),  then  falling  into  disuse  from  the  decline  of  the  disease,  were  converted 
to  quarantine  uses,  and  to  this  day  quarantine  establishments  retain  the  name  sig- 
nificant of  their  original  purposes,  namely,  lazarets. 

It  has  been  suggested  that  the  period  of  forty  days,  during  which  it  was  custom- 
ary formerly  to  enforce  isolation  and  from  which  the  designation  quarantine  is  derived, 
had  its  source  in  the  teachings  of  Hippocrates,  who,  according  to  Pythagoras,  attrib- 
uted especial  virtue,  for  the  completion  of  many  things,  to  that  period  of  time. 

The  methodical  establishment  of  quarantine  dates  from  the  Sixteenth  century, 
when  the  earliest  doctrines  of  contagion  were  also  formulated,  and  which  still  domi- 
nate to  a greater  or  less  extent  the  practice  of  quarantine.  The  plague  was  the  dis- 
ease against  which  quarantine  was  chiefly  directed  up  to  the  beginning  of  the  present 
century,  and  the  system  is  so  imbued  with  the  notions  formerly  held  as  to  plague, 
that  it  has  been  found  exceedingly  difficult,  if  not  impossible,  to  disembarrass  it 
from  them  in  endeavoring  to  apply  quarantine  to  other  forms  of  disease.  It  is 
worthy  of  note  that  as  the  plague  declined  in  western  Europe,  and  the  area  ot  its 
prevalence  in  the  Levant  became  more  restricted,  the  system  of  quarantine  seems  to 
have  become  more  elaborate.  Speculative  notions  contributed  by  experience  applied 
to  the  system  caused  it  to  be  overlaid  by  grotesque  and  unnecessary  details.  And 
notwithstanding  these  drawbacks,  the  arbitrariness  of  the  system  and  the  losses  it 
inflicted  on  commerce,  without  obvious  proportionate  gains  ; the  advantages  offered 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


325 


by  quarantine  in  the  protection  of  a country  from  pestilential  disease  appeared 
theoretically  so  great,  that  neither  administrative  follies,  nor  the  lessons  as  to  its  fal- 
lacy derived  from  experience,  nor  its  general  futility,  availed  to  bring  about  a more 
rational  system  of  protection. 

Quarantine  remained  substantially  unmodified  from  the  termination  of  the  last 
century  until  the  middle  of  the  Nineteenth  century,  since  which  time  it  has  under- 
gone great  changes  iu  rendering  the  practice  more  consistent  with  present  knowledge 
of  the  diseases  to  which  it  is  applied,  and  freeing  it  from  the  now  useless  detentions 
and  preposterous  practices. 

The  study  of  the  geographical  distribution  and  natural  history  of  diseases  has 
led  to  important  modifications  of  the  systems  of  quarantine  practiced  in  various 
countries. 

Thus  in  Great  Britain  and  Ireland,  quarantine,  which  is  carried  out  under  an  act 
of  Parliament  passed  in  the  reign  of  George  IY,  has  no  longer  a medical  significa- 
tion, and  is  practiced  solely  with  a view  of  relieving  British  maritime  commerce 
from  disabilities  which  could  else  be  imposed  upon  it  by  other  countries  in  which 
quarantine  is  regarded  as  an  essential  part  of  the  public  health  administration. 

England,  from  her  climate  and  isolated  situation,  is  peculiarly  favored  for  the 
exclusion  of  foreign  pestilence.  Thus  her  temperature  is  such  that  yellow  fever  is 
not  liable  to  gain  a serious  or  protracted  lodgment  in  her  maritime  cities. 

The  regulation  of  quarantine  in  Great  Britain  is  not  a function  of  a department 
of  the  government  which  is  concerned  with  the  sanitary  administration  of  the  king- 
dom (the  local  government  board),  but  of  the  Privy  Council  aided  by  the  Board  of 
Trade,  the  subject  being  dealt  with  as  an  International  Commercial  Question. 

The  quarantine  act  provides  for  laud  quarantine  and  the  quarantine  of  inland 
waters,  as  well  as  for  maritime  quarantine,  internal  and  external  quarantine.  It  does 
not  appear  that  internal  quarantine  has  been  practiced  in  Great  Britain  since  the  act 
was  passed ; maritime  quarantine  alone  has  been  practiced,  and  this  has  been  applied 
to  three  diseases  only,  all  of  them  infectious  diseases  of  foreign  origin,  namely, 
plague , cholera  and  yellow  fever. 

Of  plague  there  has  been  no  occurrence  in  English  ports  for  the  last  30  years, 
except  a slight  alarm  in  1879,  consequent  upon  an  outbreak  in  southeastern  Russia, 
province  of  Astrakhan.  Against  cholera,  quarantine  has  not  been  enforced  since 
1858,  its  futility  as  a precautionary  measure  in  England  having  then  been  manifested. 
Yellow  fever  is  the  sole  disease  at  present  subjected  to  quarantine  in  English  ports, 
and  this  not  from  medical  necessity,  but  from  commercial  exigencies. 

The  only  quarantine  station  now  remaining  in  England,  that  of  the  Motherbank, 
is  maintained  in  respect  of  yellow  fever.  Infectious  diseases  habitually  current  in  Eng- 
land, such  as  smallpox,  scarlet  fever,  etc. , notwithstanding  that  the  phraseology  of  the 
quarantine  act  covers  any  infectious  disease  or  distemper,  have  always  been,  iu  prac- 
tice, exempt  from  quarantine,  and  dealt  with  under  the  general  sanitaiy  law  of  the 
kingdom.  Measures  which,  in  England,  have  been  substituted  for  quarantine  against 
cholera,  consist  of  a system  of  medical  inspection , the  details  of  which  are  set  forth 
in  an  order  of  the  Local  Government  Board,  dated  1 7th  July,  1873.  This  plan  differs 
from  quarantine  in  the  following  essential  respects : — 

(a)  It  affects  only  such  ships  as  have  been  ascertained  to  be,  or  as  there  is  reason- 
able ground  to  suspect  of  being,  infected  with  cholera  or  choleraic  diarrhoea ; no 
vessel  being  deemed  infected  unless  there  has  been  actual  occurrence  of  cholera  or 
choleraic  diarrhoea  in  the  course  of  the  voyage. 

(i b ) It  provides  for  the  detention  of  the  vessel  only  so  long  as  is  necessary  for  the 


326 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


requirements  of  a medical  inspection  ; for  treatment  of  the  sick,  if  any,  in  the  man- 
ner it  prescribes,  and  for  carrying  out  the  processes  of  disinfection. 

(c)  It  subjects  the  healthy  on  board  to  detention  only  for  such  length  of  time  as 
admits  of  their  state  of  health  being  determined  by  medical  examination. 

The  measures  for  dealing  with  the  sick  under  this  order  are  but  an  adaptation  to 
a particular  exigency  of  the  principles  of  sanitary  administration  with  regard  to 
infectious  diseases  which  are  in  force  under  the  general  sanitary  laws  of  the  kingdom. 

The  relative  advantages  of  a system  of  medical  inspection  and  of  quarantine 
as  against  cholera  in  the  ports  of  Europe  underwent  thorough  discussion  at  the  Inter- 
national Sanitary  Conference  which  was  held  in  Vienna  in  1874.  A large  majority 
of  the  delegates,  including  those  from  every  State  of  the  first  rank,  except  France, 
declared  in  favor  of  the  former  system.  The  minority,  while  adhering  to  quarantine, 
agreed  to  a system  which  would  considerably  diminish  its  stringency  as  heretofore 
practiced. 

These  methods  of  inspection  and  disinfection  and  removal  of  the  sick  to  hospital 
Were  adopted  with  success  in  the  case  of  some  arrivals  from  Baltic  and  North  Sea 
ports,  with  cholera  on  board,  in  1873,  no  extension  of  the  disease  on  shore  ensuing  ; 
and  again,  in  1884,  in  the  case  of  a troop-ship,  arrived  at  Portsmouth  direct  from 
Bombay,  and  at  least  two  arrivals,  at  Liverpool  and  Cardiff,  from  Marseilles,  in  1884, 
with  cholera  on  board. 

The  last  importation  of  yellow  fever  into  the  United  Kingdom  was  at  Swansea, 
in  September,  1865,  by  a wooden  vessel  with  copper  ore  from  St.  J ago  de  Cuba.  There 
had  been  cases  of  yellow  fever  on  board  during  the  voyage,  but  at  Swansea,  as  in 
many  other  instances,  the  infection  spread  rather  from  the  ship’s  hull  and  the 
unloaded  cargo  than  from  the  crew  or  their  effects,  and  some  fifteen  deaths  ensued. 

This  yellow  fever  incident  of  1865  is  the  last  occasion  in  which  the  sanction  of  the 
quarantine  act  has  been  appealed  to.  The  quarantine  acts  are  still  unrepealed, 
but  they  may  be  said  to  have  become  practically  obsolete  in  the  United  Kingdom 
during  the  past  twenty  years. 

The  principle  of  inspection  and  isolation  of  the  sick  adopted  by  the  Sanitary  Con- 
ference at  Vienna  in  1874,  is  now  more  or  less  consistently  acted  upon  by  all  the 
larger  European  maritime  States,  except  Spain  and  Portugal. 

In  times  of  cholera  panic,  quarantine  of  the  original  kind  has  been  imposed 
against  all  arrivals  from  infected  countries  by  ports  of  the  Levant  and  Black  Sea  and 
by  several  Mediterranean  States  besides  Spain,  but  it  is  only  in  the  ports  of  the  Iberian 
peninsula  that  the  old  quarantine  traditions  remain  in  force  from  year  to  year. 

The  principal  occupation  of  the  quarantine  establishment  of  Lisbon,  Portugal,  all 
the  year  round,  is  with  arrivals  from  Brazil,  where  yellow  fever  is  endemic.  The 
Lazaretto  of  Lisbon,  which  is  probably  the  largest  and  in  ordinary  times  the  busiest 
in  the  world,  was  erected  by  the  Portuguese  Government  at  the  cost  of  over  one  . ] 
million  dollars,  and  consists  of  seven  distinct  pavilions  standing  radially  in  a semicircle 
with  the  convexity  of  the  sea,  and  is  managed  by  an  inspector,  who  is  under  the 
Minister  of  the  Interior.  Quarantine  is  imposed  as  a matter  of  fact  on  all  ships, 
passengers,  luggage  and  cargoes  coming  from  the  Brazils,  the  term  ranging  from  five  to 
seven  days,  according  as  the  Brazilian  port  is  considered  as  infected  or  suspected.  A 
bill  of  health  is  issued  to  the  captain  by  the  Portuguese  consul  at  the  port  of  sailing, 
which  usually  bears  on  it  so  many  deaths  from  yellow  fever  have  occurred  during  the 
previous  eight  or  ton  days.  If  clean  bills  of  health  were  issued  the  quarantine  would 
be  raised,  and  this  has  happened  at  short  periods  at  rare  intervals.  During  the 
winter  months,  when  the  cold  makes  the  development  of  the  yellow-fever  virus 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  327 


improbable  in  Lisbon,  if  not  impossible,  the  baggage  and  cargo  only  are  subjected  to 
quarantine,  tbe  passengers  being  allowed  to  go  ashore  at  once  with  their  hand  baggage. 
Throughout  the  rest  of  the  year  all  passengers  from  the  Brazils  have  to  go  to  the 
Lazaretto  and  stay  there  the  allotted  time,  their  effects  being  fumigated  or  disin- 
fected. 

This  rigorous  treatment  is  a concession  to  the  popular  recollection  of  the  terrible 
yellow  fever  of  1857,  when  there  were  10,000  cases  of  yellow  fever  in  and  around 
Lisbon,  with  about  6000  deaths,  the  largest  proportion  being  among  the  better  class  of 
the  population.  The  importation  was  traced  to  a tainted  ship  and  cargo  from  Bio. 

For  many  years  no  cases  of  yellow  fever  have  developed  among  the  suspected 
passengers,  and  in  only  two  or  three  instances  have  there  been  cases  of  yellow  fever 
among  the  employes. 

The  Chamber  of  Commerce  of  Lisbon  is  said  to  be  now  in  favor  of  a modification 
of  the  quarantine  law,  and  of  regulating  the  process  in  conformity  with  the  promi- 
nent facts  of  experience,  namely  : — 

(a)  That  the  fever  is  not  started  on  shore  by  personal  contact,  but  solely  by 
emanations  from  a ship’s  hull,  ballast,  cargo,  or  passengers’  effects. 

( b ) High-class  iron  steamships  are  not,  in  the  nature  of  things,  under  the  same 
suspicion  as  old  wooden  sailing  vessels. 

These  quarantine  practices  of  Lisbon  are  faithfully  copied  at  the  Azores,  Madeira 
and  Cape  V erde  Islands. 

For  Spain  there  are  two  chief  quarantine  stations  and  four  lazarettoes:  one  for  the 
Atlantic  seaboard  at  Vigo,  and  another  for  the  Mediterranean  coast  at  Port  Mahon, 
(Island  of  Minorca). 

Vessels  arriving  at  Spanish  ports  with  foul  bills  of  health  from  Havana  and  other 
West  Indian  ports  (yellow  fever)  in  ordinary  times,  and  from  many  ports  in  cholera 
times,  must  proceed  to  one  or  other  of  these  appointed  stations  to  perform  their 
quarantine.  A quarantine  of  observation,  which  is  usually  from  six  to  three  days 
and  is  imposed  upon  vessels  with  clean  bills,  may  be  performed  at  any  port. 

It  is  a standard  maxim  with  the  Madrid  Board  of  Health,  that  any  country , as 
the  United  Kingdom , which  does  not  practice  quarantine,  is,  ipso  facto , suspected , 
when  a foreign  epidemic  is  in  any  part  of  Europe  with  which  its  vessels  trade,  and 
all  arrivals  from  its  ports  may  he  subjected  to  a quarantine  of  observation. 

Next  to  Spain,  Portugal,  Turkey  and  Greece  are  the  countries  in  Europe  where 
the  old  quarantine  traditions  have  the  most  vitality,  owing,  doubtless,  to  their  near- 
ness to  the  former  seats  of  plague  in  the  Levant.  The  Lazarettoes  of  the  Pyraeus  and 
Dardanelles  are  considerable  establishments,  used  mostly  in  times  of  cholera.  There 
are  many  other  lazarettoes  in  Mediterranean  ports,  as  Malta  and  Gibraltar,  called  into 
requisition  during  cholera  epidemics. 

For  the  whole  of  the  northern  European  seaboard  quarantine  is  practically  obso- 
lete. By  Holland  quarantine  was  never  seriously  practiced,  even  for  the  plague, 
and  by  the  States  bordering  on  the  Baltic  it  was  given  up  about  tbe  same  time  that 
it  fell  into  disuse  in  Great  Britain.  In  Norwegian  ports,  subsequent  to  1866,  there 
were  3128  arrivals  from  countries  infected  with  cholera,  on  board  which  25  cases  of 
cholera  and  29  cases  of  cholerine  were  found,  but  the  malady  obtained  no  footing  on 
shore,  although  quarantine  was  not  enforced. 

In  1873,  when  cholera  was  prevalent  in  some  ports  of  the  Baltic  and  North  Seas, 
there  were  550  vessels  at  Norwegian  ports  from  infected  countries,  among  which  were 
twelve  cases  of  cholera,  but  importation  of  the  epidemic  to  the  shore  was  prevented 
simply  by  inspection  and  isolation  of  the  sick. 


328 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  Italian  ports  800  vessels  were  quarantined  in  1872,  in  only  one  of  which  was 
any  case  of  cholera  found. 

In  the  Mexican  Republic,  in  the  Central  and  South  American  Republics,  in  the 
Brazilian  Empire,  in  Peru,  Chili  and  other  South  American  States,  and  in  the  West 
Indian  colonies  and  cities,  quarantine  is  to  a large  extent  empirical,  inadequate  and 
valueless. 

In  the  North  American  Republic  no  uniform  system  prevails  among  the  indi- 
vidual States,  and  in  times  of  epidemic  visitation,  as  in  the  case  of  yellow  fever  and 
cholera,  the  people  become  the  prey  of  unreasoning  panic  and  cowardly  fear. 

It  is  true  that  New  York,  which  gathers  within  her  limits  the  largest  population 
of  any  North  or  South  American  city  of  past  or  present  times,  has  been  foremost  in 
enlightened  quarantine  reform  and  advancement,  and  she  has  been  first  to  adopt 
an  enlightened  and  liberal  system,  based  upon  the  following  important  facts : — 

(a)  Mere  detention,  without  careful  medical  inspection,  isolation  of  the  sick  and 
thorough  ventilation,  fumigation,  cleansing  and  disinfection  of  the  ship,  cargo,  ballast 
and  clothing  and  baggage  of  the  passengers,  is  valueless. 

(b)  The  chief  danger  with  reference  to  the  spread  of  yellow  fever  lies  in  the  hold 
of  the  ship,  in  her  foul  bilge  water  and  infected  cargo,  ballast  and  baggage  of  her 
crew  and  passengers. 

(c)  Each  ship  should  be  judged  upon  her  own  merits,  her  own  sanitary  history 
and  condition  after  through  inspection. 

( d ) First-class  iron  and  steel  steam  vessels  should  not  be  placed  upon  the  same 
footing  as  old  wooden  sailing  vessels. 

(e)  Those  unacclimated  persons  who  work  on  board  infected  vessels  are  liable  to 
contract  yellow  fever. 

By  an  enlightened  system  of  quarantine,  the  health  authorities  of  New  York 
have  not  merely  removed  many  useless  and  onerous  restrictions  from  commerce, 
but  they  have  also  protected  this  great  city,  for  more  than  half  a century,  from  the 
invasions  of  yellow  fever,  which  bad  been  so  frequent  during  the  preceding  century. 

Louisiana,  who  lost  nearly  50,000  of  her  citizens  during  the  first  seventy-eight  years 
of  the  Nineteenth  century,  has  been  steadily  perfecting  her  quarantine  system  since 
the  year  1855,  and  her  chief  city,  holding  the  key  to  the  Mississippi  Valley,  has,  by 
her  enlightened  and  rigid  quarantine,  excluded  yellow  fever  during  the  past  decade. 

On  the  other  hand,  the  great  State  of  Texas  is  without  a rational  system  of 
quarantine,  and  the  quarantine  establishments  and  systems  of  Mississippi,  Alabama, 
Florida,  Georgia  and  South  Carolina  need  revision  and  reconstruction.  As  far  as 
this  North  American  Republic  is  concerned  in  the  perfection  and  conduct  of  quar- 
antine, we  would  respectfully  suggest  the  careful  consideration  of  the  following 
questions : — 

(a)  Shall  the  general  governments  of  the  civilized  world  assume  control  of  all  the  . 
quarantine  systems,  and  by  mutual  consent  reduce  the  entire  subject  of  quarantine 
to  order,  and  apply  the  most  improved  methods  of  sanitation  and  disinfection? 

(i b ) Shall  the  Government  of  the  United  States  assume  charge  of  the  entire  sub- 
ject of  quarantine  within  her  borders,  and  relieve  the  individual  States  of  all  further 
responsibility  of  regulating  not  merely  foreign,  but  also  interstate  quarantine? 

The  object  in  propounding  questions  a and  b is  for  the  purpose  of  bringing  about 
a grand  union  of  action  on  the  part  of  all  civilized  nations  on  the  subject  of  quaran- 
tine, so  as  to  advance  the  cause  of  medical  science  and  humanity.  As  matters  now 
stand,  commerce  is  made  to  bear  the  brunt  of  quarantine.  The  unfortunate  ship 
stricken  by  pestilence  suffers  delay,  and  in  some  cases  immense  expense.  The  unfor- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE  329 


tunate  crew  and  passengers,  who  have  committed  no  crime,  are  treated  like  outcasts 
and  outlaws ; they  appear  to  have  no  rights  which  humanity  is  supposed  to  respect. 

Commerce  bears  in  its  bosom  the  germs  of  civilization ; commerce  establishes 
and  sustains  the  markets  of  the  world ; commerce  is  the  agent  for  the  dissemination 
of  all  that  is  grand  and  noble  in  the  life  and  development  of  our  common  humanity ; 
and  the  brave  and  hardy  sons  of  commerce  have,  in  all  ages  and  in  all  times,  rallied 
to  the  defence  of  their  native  lands. 

Is  it  just,  is  it  right,  that  the  pestilence-stricken  ship  should  bear  all  her  expenses, 
and  suffer  all  that  the  safety  of  man  may  demand,  and  that  avarice  and  cowardice 
may  suggest?  Has  not  civilization  advanced  to  that  stage,  and  are  not  the  great 
civilized  and  Christian  powers  of  the  world  (the  United  States  of  America,  the  British 
Empire,  France,  Grermauy,  Austria,  Russia,  Denmark,  Norway,  Sweden,  Italy,  Spain 
and  Portugal)  sufficiently  strong,  wealthy  and  enlightened  to  establish  a uniform 
system  of  quarantine,  which  shall  embrace — 

1st.  A system  of  mutual  confidence ; a uniform  system  of  registration  of  diseases 
and  deaths. 

2d.  A system  of  regular  health  reports,  giving  detailed  statements  at  regular 
intervals — daily,  weekly,  monthly  and  annually — of  all  matters  relating  to  the  public 
health,  to  the  sanitary  welfare  of  nations. 

By  the  use  of  the  telegraph,  all  civilized  nations  could  be  kept  informed  of  the 
appearance,  spread  and  arrest  of  any  contagious  or  infectious  disease,  as  smallpox, 
cholera  and  yellow  fever. 

3d.  A uniform  system  of  quarantine  adapted  to  the  climate,  latitude  and  endemic 
and  epidemic  diseases  of  each  nation.  By  a uniform  system,  we  mean  uniformity  in 
the  construction  of  quarantines  and  their  administration,  and  the  uniform  assumption 
by  the  great  Powers  of  the  world  of  all  quarantine  expenses  of  cleansing,  discharge 
of  cargo,  disinfection  and  fumigation,  and  of  the  care  and  treatment  of  the  sick. 
The  only  expense  necessarily  borne  by  the  pestilence-stricken  ship,  or  suspected  ship, 
detained  in  quarantine,  would  be  the  loss  of  time,  and  the  necessary  expense  for  food, 
etc. , of  the  crew  and  passengers. 

As  quarantine  is  now  conducted,  the  owners  of  ships,  as  well  as  their  passengers 
and  crews,  suffer  often  unequally  and  unjustly  for  the  public  good. 

The  two  questions  are  complementary  the  one  to  the  other ; b flows  necessarily 
from  a ; to  be  of  any  practical  value,  the  discussion  of  a must  precede  that  of  b ; a 
cannot  be  construed  as  relating  to  any  government  but  the  United  States  of  America 
and  its  individual  States,  and  does  not  refer  to  foreign  States,  only  so  far  as  that  the 
United  States  may  become  one  of  the  contracting  parties  under  proposition  a. 

The  high  purpose  of  this  discussion  is  clear ; it  is  designed  for  the  benefit  of  all 
civilized  nations;  it  is  designed  to  lead  ultimately  to  the  establishment  of  uniform 
national  and  international  quarantine  laws , quarantine  methods , and  quarantine 
administration  and  charges. 

We  will  conclude  this  branch  of  our  subject  by  the  following  recommendations 
for  the  advancement  of  international  hygiene  : — 

1.  The  appointment  of  one  or  more  competent  medical  men,  thoroughly  informed 
with  reference  to  questions  relating  to  public  and  international  hygiene , including  all 
that  relates  to  quarantine  by  the  individual  States  of  the  United  States  of  North 
America. 

Said  representatives  shall  be  regularly  commissioned  by  the  governors  of  the 
respective  States,  and  shall  be  empowered  to  deliberate  upon  all  questions  relating 
to  quarantine,  and  to  formulate  a uniform  system  of  hygienic  rules  adapted  to  the 


330 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


differences  of  climate,  location,  natural  products  and  commercial  and  agricultural 
relations  of  the  various  sections  of  this  Union,  which  shall  govern  the  foreign  and 
interstate  trade  and  commerce  and  intercourse  at  all  times  of  health  and  of  pesti- 
lential visitation. 

2.  The  appointment  of  a representative  or  representatives  by  the  United  States 
of  America,  by  the  Mexican  Republic,  and  by  each  of  the  Central  and  South 
American  Republics,  by  all  the  governments  of  the  West  India  Islands,  and  by 
the  Brazilian  Empire,  to  investigate  the  sanitary  condition  of  all  the  chief  seaports  of 
North  and  South  America. 

The  duty  of  this  international  hygienic  congress  shall  be  to  formulate  suggestions 
for  the  sanitary  improvement  and  quarantine  regulation  of  all  the  important  com- 
mercial centres  of  North,  South,  Central  and  insular  America. 

If  any  effort  is  to  be  made  by  the  nations  to  eradicate  the  cause  of  yellow  fever, 
and  to  free  commerce  from  the  restrictions  which  its  dread  imposes,  this  effort  must 
commence  with  the  sanitary  improvement  of  such  cities  as  Yera  Cruz,  Havana, 
Panama  and  Rio  de  Janeiro. 


APPENDIX. 

When  we  consider  the  vast  importance  of  Hygiene  to  the  welfare  of  the  human  race,  and  the 
value  of  correct  systems  of  disinfection  and  sanitation,  the  history  of  the  gradual  development  of 
this  science  in  its  application  to  the  arrest  of  contagious  and  infectious  diseases  possesses  peculiar 
interest.  > , 

It  would  be  foreign  to  the  present  discussion  to  enter  into  any  extended  review  of  the  great 
advances  which  have  been  made  in  sanitary  science,  but  we  may  be  permitted  to  allude  to  certain 
well-established  facts. 

Thus,  during  the  Middle  Ages  the  characters  of  the  epidemic  fevers  were  modified,  and 
their  destructive  tendencies  intensified,  and  their  external  manifestations  rendered  more  marked, 
by  the  neglect  of  all  sanitary  regulations  in  cities  and  private  houses,  and  by  the  filthy  habits 
and  salt  diet  of  the  people.  Every  town  was  a fortress,  and  every  house  a castle,  and  the  inhabit- 
ants, like  the  soldiers  of  a garrison,  worked  and  slept  with  their  arms,  and  always  held  them- 
selves ready  to  resist  attacks.  Bands  of  robbers  defied  the  power  of  the  rulers,  openly  encamped 
upon  the  public  roads,  and  plundered  and  murdered  all  who  were  not  able  to  protect  themselves 
by  the  force  of  arms.  The  country  was  covered  with  forests  and  undrained  swamps  and  marshes, 
and  the  best  lands  were  uncultivated.  Tho  walled  towns  were  encompassed  by  large,  stagnant 
ditches,  which  were  the  receptacle  for  refuse  and  all  sorts  of  decomposing  filth ; tho  streets  were 
narrow,  unpaved,  undrained,  uncleaned  and  unlightod  ; there  was  no  provision  for  the  removal 
of  the  town  refuse,  which  was  thrown  into  the  gutters  and  streets,  forming,  in  dry  weather,  a 
semi-fluid  mass  of  corrupting  animal  and  vegetable  matter,  and,  in  wet  weather,  noxious  bogs  of 
filth.  The  houses  were  described  as  mean  and  squalid,  without  chimneys,  the  windows  without 
glass,  and  tho  floors  without  boards.  The  floors,  says  Erasmus,  “ generally  are  made  of  nothing 
but  loam,  and  are  strewed  with  rushes,  which  being  constantly  put  in  fresh,  without  tho  removal 
of  the  old,  remain  lying  there,  in  some  cases  for  twenty  years,  with  fish  bones,  broken  victuals, 
tho  dregs  of  tankards,  and  impregnated  with  other  filth  underneath,  from  dogs  and  men.” 

From  tho  absence  of  cotton  and  linen  goods,  and  tho  scarcity  of  woolen  garments,  resulting 
from  tho  slow  production  of  cloths  by  the  hand-loom,  the  personal  habits  of  tho  pooplo  wore  filthy 
in  tho  extreme.  Combined  with  this  there  existed  ignorance  as  to  tho  inodo  of  raising  and  pre- 
serving vegetables,  and  improvidence  and  intcmporanco  of  living.  For  many  centuries  no  rnoro 
subsistence  was  produced  in  Europo  than  was  barely  sufficient  for  the  necessities  of  the  people. 
Consequently,  every  year  of  scarcity  bocame  a year  of  famine.  Tho  malarious,  undrained  state  of 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  331 


the  country,  the  crowded,  filthy  condition  of  the  towns,  and  the  filthy,  degraded  habits  of  the 
people,  formed  tho  necessary  conditions  for  the  origin  and  spread  of  contagious  diseases,  which 
almost  annually  desolated  the  more  thickly  populated  cities  and  countries. 

During  the  past  two  centuries,  tho  great  revolution  wrought  by  changes  of  diet,  dress  and  habits, 
and  tho  great  advance  of  tho  arts  of  civilization,  and  the  application,  in  public  and  private  build- 
ings, and  in  cities  and  towns,  of  correct  sanitary  regulations,  have  banished  many  destructive 
diseases  and  mitigated  the  severity  of  others. 

The  plague,  which  ravaged  Europe  for  more  than  two  thousand  years,  disappeared  two  cen- 
turies ago,  and  now  only  lingers  in  the  more  ancient  and  filthy  Eastern  cities.  Tho  labors  of  the 
agriculturists  have  banished  malarial  fever  from  large  portions  of  the  European  and  American 
continents;  typhus  or  jail  fever,  the  fatal  scourge  of  the  unfortunato  prisoner,  of  the  sailor  and 
soldier,  or  of  the  inmates  of  tho  crowded  hospital,  and  which  in  many  of  its  visitations  was 
scarcely  less  terrible  than  the  plague,  is  now  confined  to  the  hovels  of  the  poor  in  certain 
oppressed  and  suffering  countries,  and  is  almost  unknown  among  the  better  classes.  Many  pain- 
ful and  fatal  forms  of  disease  which  formerly  swelled  the  bills  of  mortality  in  the  large  European 
cities  have  so  completely  disappeared  that  their  names  even  are  no  longer  in  use;  and  smallpox, 
which  before  the  discovery  of  vaccination  by  Jenner  was  infinitely  more  destructive  than  the 
plague  itself,  sweeping  off  whole  tribes  of  savage  and  half  civilized  people,  and  destroying  not  less 
than  fifteen  millions  of  human  beings  every  twenty-five  years,  exists  only  because  of  our  neglect 
and  folly. 

It  is  the  duty  of  the  physician  to  prevent,  as  well  as  to  cure  disease,  and  all  questions  relating 
to  sanitary  science  should  be  discussed  with  calmness,  deliberation  and  justice.  In  the  discussion 
of  any  and  every  measure  which  relates  to  the  prevention  and  control  of  these  pestilences,  and 
especially  of  yellow  fever,  which  have  at  various  times  inflicted  incalculable  injury  upon  the 
maritime  cities  of  Insular,  Central  and  North  and  South  America,  it  would  be  well  for  the  guar- 
dians of  the  public  health  to  consider  the  advice  of  a noble  Roman  to  the  Senate:  “All  who 
deliberate  upon  doubtful  matters  ought  to  be  uninfluenced  by  hatred,  affection,  anger  or  pity. 
When  we  are  animated  by  these  sentiments  it  is  hard  to  unravel  the  truth,  and  no  one  has  been 
able  to  serve  at  once  his  passions  and  his  interests.”  All  facts  relating  to  the  origin,  cause  and 
means  of  prevention  of  yellow  fever,  are  of  vital  importance  to  the  inhabitants  of  southern  cities. 
A correct  knowledge  of  the  laws  which  govern  yellow  fever  can  be  obtained  only  by  the  accumu- 
lation of  a large  number  of  well-observed  and  undoubted  facts,  and  tho  medical  profession  will 
sustain  and  encourage  legitimate  and  efficient  measures  designed  to  limit  or  prevent  the  spread 
of  this  disease. 

Whoever  may  he  instrumental  in  the  discovery  and  establishment  of  the  laws  which  govern 
the  origin  and  spread  of  this  great  scourge,  will  certainly  be  entitled  to  the  gratitude  of  the 
inhabitants  of  insular,  tropical  and  sub-tropical  America. 

If  it  be  true  that  the  localizing  causes  of  yellow  fever,  and  the  high  death  rate  of  certain 
cities  in  insular,  tropical  and  sub-tropical  America,  be  preventable  in  New  Orleans  and  other 
cities,  then  it  is  of  prime  importance  to  the  public  welfare  that  the  medical  profession  should 
calmly  discuss  every  experimental  procedure  directed  to  the  control  or  removal  of  tho  local 
causes  of  disease  and  death. 

DISINFECTION  PRACTICED  BY  THE  ANCIENTS,  BUT  ITS  SCIENTIFIC  INVESTIGATION  OF 

MODERN  ORIGIN. 

The  word  disinfection  is  applied  to  the  removal  of  all  disagreeable  gases  and  odors,  as  well  as 
to  the  decomposition  which  produces  them,  and,  therefore,  includes  deodorizing;  and  the  use  of 
the  word  in  this  sense  is  in  accordance  with  the  opinion  held  from  the  earliest  ages,  that  the 
infection  of  fever  or  plague  was  either  the  same  as,  or  distinctly  allied  to,  these  gases. 

The  preservation  of  meats  by  smoking,  drying  and  pickling  with  salt,  and  of  vegetables  and 
fruits,  by  mean3  of  honey  and  sugar,  is  a kind  of  disinfection  which  was  practiced  from  time 
immemorial;  Moses,  tho  lawgiver,  established  specific  hygienic  rules  for  camps  and  cities; 
described  with  great  care  the  modes  of  disinfecting  vessels,  clothing  and  houses  contaminated  with 
putrid  or  infectious  matter;  pleasant  scents  were  used  not  merely  for  pleasure,  but  during  all 
epidemics,  perfumes  and  substances  with  decided  odors,  were  everywhere  employed  asdisinfectants 
• or  guards  against  infection  and  contagion.  The  use  of  such  antiseptics  as  resins,  pitch  or  tar, 


I 


332 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


bitumen,  aromatics,  natron  or  nitre  and  cedar  oil,  in  the  process  of  embalming  the  dead  bodies  of 
man  and  animals  was  known  to  the  Egyptians  before  any  authentic  history  which  books  have 
handed  down.  The  Greeks  and  Romans,  at  an  early  day,  directed  their  attention  to  the  evil 
effects  of  crowding,  and  enacted  laws  for  the  proper  construction  of  houses.  In  Rome  the  houses 
were  ordered  to  be  at  least  five  feet  apart,  and  not  more  than  nine  stories  high.  Augustus  com- 
manded that  they  should  not  exceed  seventy  feet  in  height.  Trajan  made  the  limit  seventy. 
Zeno,  of  Constantinople,  ordered  all  houses  to  be  twelve  feet  apart  all  the  way  up,  and  the  projec- 
tions which  caused  the  houses  to  meet  above  were  disallowed.  The  disinfection  and  cleansing  of 
the  streets  and  sewers  was  the  duty  of  a high  officer  in  Rome.  “The  Praetor  took  care  that  all 
sewers  should  be  cleansed  and  repaired,  for  the  health  of  the  citizens,  because  uncleaned  or  unre- 
paired sewers  threaten  a pestilential  atmosphere,  and  are  dangerous.’’  And  finally,  from  the  days 
of  Ilomer  and  Hippocrates,  of  the  great  plague  of  Athens  to  the  present  moment,  the  burning 
of  sulphur  and  tar  have  been  practiced  for  the  arrest  of  pestilence. 

As  the  art  of  disinfection  borrows  its  knowledge  from  chemistry,  it  has  advanced  in  accord- 
ance with  the  general  advances  of  this  science,  which  is,  to  a large  extent,  of  modern  creation, 
and  it  may  at  some  future  day  attain  the  rank  of  a science,  when  the  nature  of  contagious  and 
infectious  matters  have  been  fully  revealed,  and  the  direct  chemical  and  physical  actions  of 
disinfectants  established. 

Much  ingenuity  and  force  of  argument  have  been  exerted  by  some  authors,  to  show  that  con- 
tagion is  the  mere  result  of  putrefaction,  but  though  many  circumstances  serve  to  prove  that 
they  are  intimately  connected,  and  capable  of  being  destroyed  by  similar  agents,  sufficient  evi- 
dence has  not  hitherto  heen  adduced  to  warrant  the  positive  conclusion  that  contagious  effluvia 
are  essentially  the  same  with  the  miasmata  exhaled  from  putrid  substances.  Whatever  difference 
of  opinion  may,  however,  prevail  respecting  the  nature  and  origin  of  febrile  contagions,  accurate 
observations  have  fully  proved  that,  in  whatever  way  generated,  they  may  all  be  propagated, 
either  by  actual  contact  with  infected  persons  or  things,  or  by  breathing  air  charged  with  effluvia, 
whether  proceeding  from  substances  imbued  with  contagious  virus,  or  from  patients  laboring 
under  pestilential  disease. 

Since  all  contagious  effluvia  act  only  when  near  to  the  sources  whence  they  arise,  and  since, 
when  diffused  in  the  air,  or  chemically  united  with  it  by  solution,  they  unquestionably  lose  their 
deleterious  qualities,  it  must  be  obvious  that,  by  a proper  attention  to  ventilation  and  cleanliness, 
the  influence  of  infection  may  be  generally  avoided;  but  although  both  reason  and  experience 
confirm  the  efficacy  of  such  measures  in  preventing  or  controlling  the  destructive  agency  of  con- 
tagion, yet,  as  the  time  requisite  thus  to  dilute  or  diffuse  the  poison  is  uncertain,  and  as  this  mode 
of  purification  is  not  universally  applicable,  recourse  has  been  had  to  the  more  easy  and  expedi- 
tious means  which  chemistry  affords. 

While  the  modern  history  of  disinfectants  began  in  the  Seventeenth  century,  it  was  not  until 
near  the  close  of  the  Eighteenth  century  that  the  nature  and  agencies  of  oxygen  and  chlorine 
were  explained  by  the  discoveries  of  Priestley,  Scheie,  Cavendish,  Lavoisier,  and  other  chemists. 
The  investigations  of  Boyle,  showing  the  influence  of  air  and  heat  and  cold  upon  putrefaction, 
were  followed  by  the  experiments  of  Dr.  Petit,  in  1732,  on  the  effects  of  antiseptics  in  the  preser- 
vation of  flesh.  Petit  came  to  the  conclusion  that  astringents  were  the  best  preservatives  of 
fresh  meats,  and  that  their  action  was  similar  to  drying.  Lord  Bacon  had  long  before  observed 
that  the  inducing  or  accelerating  putrefaction  was  a subject  of  very  universal  inquiry,  and  says 
that  “ it  is  of  an  excellent  use  to  inquire  into  the  means  of  preventing  or  staying  putrefaction, 
which  makes  a great  part  of  physic  and  surgery.”  * 

NOTE  1.  EXPERIMENTS  OF  SIR  JOHN  PRINGLE,  1750. 

In  1750,  Sir  John  Pringle  read  before  tho  Royal  Society  his  “Experiments  upon  Septic  and 
Antiseptic  substances,  with  remarks  relating  to  their  use  in  tho  Theory  of  Medicine,” f for  which 
he  was  honored  with  the  Copleian  Medal.  Sir  John  Pringle  was  led  to  make  some  experiments 
into  the  manner  in  which  bodies  are  resolved  by  putrefaction,  with  the  moans  of  accelerating,  or 

* Nat.  History,  Cent.  iv. 

f Philosophical  Transactions,  1750,  Vol.  xlvi,  No.  495,  p. 481 ; No.  490,  p.  525,  p.  550.  “Observations  on 
Diseases  of  the  Army,”  by  Sir  John  Pringle.  Appendix. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  333 


preventing  that  process,  by  his  having  had  “an  uncommon  number  of  putrid  distempers”  under 
his  caro  in  the  hospitals  of  the  Army. 

From  the  first  series  of  experiments  he  concluded  that  acids  by  themselves  were  among  the 
most  powerful  antiseptics,  and  that  the  alkaline  salts  were  likewise  of  that  class.  Sir  John 
Pringle  thus  rates  the  comparative  powers  of  salts  in  resisting  putrefaction : sea  salt,  1 ; sal 
gemmae,  1 ; Tartarus  vitriolatus,  2 ; Spiritus  mindereri,  2 ; Tartarus  solubilis,  2;  Sal  diureticus,  2; 
Sal  ammoniacus,  3;  Saline  mixture,  3;  Nitre,  4;  Salt  of  hartshorne,  4;  Salt  of  wormwood,  4; 
Borax,  12;  Salt  of  amber,  20;  Alum,  30.  According  to  this  table  the  antiseptic  power  of  alum 
is  thirty  times  as  great  as  that  of  common  salt.  He  experimented  also  upon  the  antiseptic  prop- 
erties of  Myrrh,  Aloe,  Asafcetidae,  Terra  japonica,  Gum  ammoniacum,  Opium  and  Camphor. 
Of  all  resinous  substances,  he  found  camphor  to  be  the  strongest  “resister  of  putrefaction.”  Ex- 
periments with  infusions  of  Virginia  snake  root,  Peruvian  bark,  pepper,  ginger,  saffron,  contra- 
erva  root,  galls,  dried  sage,  rhubarb,  root  of  wild  valerian,  leaves  of  mint,  angelica,  ground  ivy, 
senna,  green  tea,  red  roses,  wormwood,  mustard  seed  and  horse-radish  root,  proved  that  they  were 
powerful  “resisters  of  putrefaction.” 

After  detailing  various  experiments  illustrating  the  power  of  a decoction  of  Peruvian  bark  to 
arrest  putrefaction,  Sir  John  Pringle  makes  the  following  practical  applications: — 

“Now,  since  the  bark  parts  with  so  much  virtue  in  water,  is  it  not  reasonable  to  suppose  that 
it  may  yield  still  more  in  tliQ  body,  when  opened  by  the  saliva  and  the  bile,  and  therefore  that 
in  some  measure  it  operates  by  this  antiseptic  virtue  ? From  this  principle  we  may,  perhaps, 
account  for  its  success  in  gangrene,  and  in  the  low  state  of  malignant  fevers  when  the  humours 
are  apparently  corrupted.  And  as  to  intermitting  fevers,  in  which  the  bark  is  most  specific, 
were  we  to  judge  of  their  nature  from  the  circumstances  attending  them,  in  climates  and  in 
seasons  most  liable  to  this  distemper,  we  should  assign  putrefaction  as  one  of  the  principal  causes. 
They  are  the  great  epidemics  of  marshy  countries,  and  prevail  most  after  hot  summers,  with  a 
close  and  moist  state  of  the  air.  They  begin  about  the  end  of  summer  and  continue  throughout 
autumn,  being  at  the  worst  when  the  atmosphere  is  most  loaded  with  the  effluvia  of  stagnating 
water,  rendered  more  putrid  by  vegetables  and  animals  dying  and  rotting  in  it.  At  such  times 
all  meats  are  quickly  tainted,  and  dysenteries,  with  other  putrid  disorders,  coincide  with  these 
fevers.  The  heats  dispose  the  blood  to  acrimony,  the  putrid  effluvia  are  a ferment,  and  the  fogs 
and  dews,  so  common  in  such  situations,  stopping  perspiration,  shut  up  the  corrupted  humours 
and  bring  on  a fever.  The  more  these  causes  prevail,  the  easier  is  it  to  trace  this  putrefaction. 
The  nausea,  thirst,  bitter  taste  in  the  mouth  and  frequent  evacuations  of  corrupted  bile,  are 
common  symptoms  and  arguments  for  what  is  advanced.  We  shall  add  that  in  moist  coun- 
tries and  in  bad  seasons,  the  intermittents  not  only  begin  with  symptoms  of  a putrid  fever,  but  if 
unduly  treated,  are  easily  changed  into  a malignant  fever  with  livid  spots  or  blotches  on  the 
skin  or  a mortification  of  the  bowels.  At  the  same  time  it  must  be  acknowledged  that  such  is  the 
quick  action  of  the  bark  in  removing  these  fevers  that  its  febrifuge  quality  must  be  something 
different  from  its  antiseptic:  and  yet  we  may  remark  that  whatever  medicines  (besides  evacua- 
tions and  the  bark)  have  been  found  useful  in  the  cure  of  intermittents,  they  are  mostly,  so  far  as 
I know,  powerful  correctors  of  putrefaction,  such  as  myrrh,  camomile-flowers,  wormwood, 
tincture  of  roses,  alum  with  nutmeg,  the  vitriolic  or  other  strong  mineral  acids,  with  aromatics.” 

NOTE  2.  VENTILATION  OF  SHIPS  IN  1755.  BY  DR.  STEPHEN  HALES. 

In  1755,  Dr.  Stephen  Hales*  published  in  the  Transactions  of  the  Royal  Society  of  London, 
an  article  “On  the  Great  benefits  of  Ventilators  in  many  instances,  in  preserving  the  health  and 
lives  of  people  in  slave  and  other  transport  ships.” 

Captain  Thomson,  of  the  “Success  ” frigate,  in  a letter  to  Dr.  Hales  dated  London,  Sept.  25th, 
1749,  states  that  he  “found  this  good  effect  from  ventilation,  that  though  there  were  near  200 
men  on  board  for  almost  a year,  yet  he  landed  them  all  well  in  Georgia,  notwithstanding  they 
were  pressed  men  and  drawn  out  of  jails  with  distempers  upon  them.” 

He  states  also  that  all  kinds  of  provisions  in  the  ship  kept  better,  from  the  coolness  and  fresh- 
ness of  the  air  in  the  ships,  caused  by  ventilation.  Mr.  Crammond  and  Captain  Ellis  testified  to 
the  value  of  free  ventilation  in  preserving  the  lives  of  the  crew  and  slaves  during  the  voyages  from 


* Philosophical  Transactions , 1755,  Vol.  XLIX,  p.  332. 


334 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Africa  to  America.  Also  the  Earl  of  Halifax,  often  informed  Dr.  Hales  of  the  great  benefit  they 
found  by  the  uso  of  ventilators  in  several  Nova  Scotia  transport  ships,  twelve  to  one  more  having 
been  found  to  die  in  unventilated  than  in  ventilated  ships. 

In  view  of  such  facts,  Dr.  Hales  affirmed  that  “ It  is  indeed  a self-evident  thing  that  this  chang- 
ing the  foul  air  frequently  in  ships  in  which  there  are  many  persons,  will  be  a means  of  keeping 
them  in  better  health  than  not  doing  it.  It  is  the  high  degree  of  putrefaction  (that  most  subtle 
dissolvent  in  nature),  which  a foul  air  acquires  in  long  stagnating,  which  gives  it  that  pestilential 
quality  which  causes  what  is  called  the  jail  distemper.  And  a very  small  quantity,  or  even 
vapor  of  this  highly  attenuated  venom,  like  the  infection  or  inoculation  for  the  smallpox,  soon 
spreads  its  deadly  infection.” 

NOTE  3. 

Dr.  John  Huxham,  in  his  Essay  on  Fevers,  * in  the  Appendix,  details  a method  of  pre- 
serving the  health  of  seamen  in  long  cruises  and  voyages,  and  advises  that  “ Every  sailor 
should  have  at  least  a pint  of  cider  a day,  besides  beer  and  water.  And  I would  advise,  also,  a 
frequent  and  free  use  of  vinegar  in  the  seaman’s  diet;  especially  when  the  provisions  begin  to 
grow  rancid.  Besides  this,  the  decks,  etc.,  should  be  frequently  washed  or  sprinkled  with  vinegar; 
after  having  drawn  the  gross  and  foul  air  out  of  the  ship  by  Mr.  Sutton’s  contrivance,  or  by  Dr. 
Hales’  ventilators,  which  should  be  done  once,  at  least,  every  day.” 

NOTE  4.  EXPERIMENTS  OF  DR.  DAVID  MACBRIDE,  IN  1764,  ON  ANTISEPTICS. 

Surgeon  David  Macbride  published,  in  1764,  his  Five  Experimental  Essays  on  the  Fermenta- 
tion of  Alimentary  Mixtures,  Fixed  Air,  Antiseptics,  Scurvy  and  the  Resolvent  Power  of  Quick- 
lime, f 

The  old  chemists  believed  that  all  the  true  spontaneous  changes  or  transmutations  of  bodies 
were  the  effects  of  fermentation;  but  Boerhaave,  disliking  so  enormous  an  extension  of  terms 
restricted  it  within  very  narrow  limits,  and  would  suffer  nothing  to  be  called  fermentation  which 
did  not  produce  either  an  ardent  spirit  or  an  acid,  thus  entirely  confining  it  to  what  are  usually 
called  the  vinous  and  acetous  stages,  and  altogether  rejecting  the  putrefactive,  as  looking  on  putre- 
faction to  be  quite  a different  process,  and  no  way  allied  to  fermentation.  But  this  restriction, 
which  was  merely  for  the  sake  of  clearness  and  precision,  introduced  confusion  with  regard  to  the 
word  putrefaction.  This  word,  in  its  common  acceptance,  was  always  understood  to  imply  a plain 
tendency  to  destruction  in  bodies,  accompanied  with  every  sign  of  rottenness  and  offensiveness; 
and,  accordingly,  it  was  often  met  with  in  cotemporary  writers  with  Macbride,  in  this  sense,  when 
perhaps,  on  the  very  same  page,  the  statement  is  made  that  the  aliment  is  prepared  for  nourishing 
the  human  body  by  putrefaction;  that  motion,  life  and  heat  are  communicated  to  the  fluids  by 
putrefaction. 

The  later  chemists,  therefore,  who  reduced  this  branch  of  chemistry  to  a more  intelligible  and 
methodical  system  than  Boerhaave,  approached  more  nearly  to  the  ancient  opinion,  and  with 
Macquer,  defined  fermentation  to  be  an  intestine  motion,  which,  arising  spontaneously  among  the 
insensible  parts  of  a body,  produceth  a new  disposition  and  a different  combination  of  the  parts. 

Macbride,  accepting  this  definition,  held  that  a great  number  of  tho  natural  changes  which 
daily  take  place  in  the  animal  and  vegetable  kingdoms  should  be  looked  on  as  so  many  modes  of 
fermentation,  and  that,  in  particular,  the  digestion  of  our  food  should  be  looked  on  as  nfermenta- 
tory  process. 

Macbride  held  that  “ the  experiments  already  made  by  the  very  learned  and  ingenious  Dr. 
Pringle,  seem  sufficient  to  convince  every  unbiased  reader  of  the  truth  of  this  theory,  which, 
if  wo  consider  the  matter  with  any  degree  of  attention,  we  must  find  to  be  absolutely  necessary 
in  order  to  bring  about  that  new  disposition  and  that  diff  erent  combination  of  the  insensible  parts 
of  the  alimentary  substances  which  enable  the  immense  variety  of  discordant  mixtures  thut  enter 
the  composition  of  our  food  to  depart  so  far  from  their  original  natures  ns  to  become  one  mild, 
sweet  and  nutritious  fluid ; for  this  demands  a great  deal  more  than  mere  mechanical  mixture  and 
dissolution,  which  is  the  most  that  the  common  theories  of  digestion  lead  to,  since  they  do  not 
seem  expressly  to  require,  nor  indeed  suppose,  such  an  absolute  change  to  be  wrought,  in  tho  first 


* Third  Ed.,  London,  1757,  page  262. 


f London,  1764. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  335 


passages,  on  the  nature  of  the  different  kinds  of  food,  as  would  render  them  susceptible  of  that 
firm  union  and  that  strong  attraction  by  the  means  of  which  they  become  so  soon  one  and  the  same 
substance  with  the  body  into  which  they  are  received. 

It  also  appears  pretty  plain,  from  Dr.  Pringle’s  experiments,  that  there  is  something  gener- 
ated or  set  free  during  the  first  stage  of  the  fermentation  of  animal  and  vegetable  mixtures, 
which  hath  a power  of  correcting  putrefaction.”  * 

Hoffman,  however,  previous  to  Maebride,  had  insisted  much  on  the  complete  change  that  the 
aliment  undergoes  in  the  first  passages,  and  makes  digestion  a mere  fermentatory  process,  as  may 
be  seen  at  large  in  his  chapter  de  Alimentorum  Solutione  and  Solutione  Usu,  and  the  three  suc- 
ceeding ones. 

The  labors  of  Hoffman,  Pringle  and  Maebride  were  of  the  highest  importance,  in  that  they 
referred  putrefaction,  fermentation  and  digestion  to  the  same  general  causes. 

Maebride  repeated  and  extended  the  experiments  of  Pringle,  and  confirmed  his  conclusions, 
that  combinations,  as  the  mineral  acids,  aromatic  gums  and  Peruvian  bark,  possess  powerful  anti- 
septic virtues,  resisting  and  correcting  putrefaction.  He  also  established  the  fact  that  fixed  air 
(carbonic  acid)  tended  to  retard  fermentation. 

Maebride  threw  out  the  following  suggestions  with  reference  to  the  treatment  of  yellow  fever: — 
“ However,  I will,  in  the  meantime,  recommend  the  trial  of  an  experiment  in  that  very 
destructive  disease,  the  putrid  yellow  fever  of  the  West  Indies.  It  is  to  give  the  patients  repeated 
doses  of  the  alkaline  salts,  in  fresh  lime  juice,  or  the  like,  and  let  it  always  be  swallowed  during 
the  act  of  effervescence;  and  let  the  patient’s  drink  be  somewhat  of  the  highly  fermentable  kind; 
I would  even  propose  the  juice  of  the  green  sugar  cane,  diluted,  and  acidulated  with  some  of  the 
recent  sour  juices.” 

“ I find  that  Dr.  Lind  often  prevents  the  fits  of  an  ague  by  giving  these  mixtures  in  the 
manner  above  mentioned.  And  Riverius  used  to  check  vomitings  therewith  in  an  infant.” 

“A  surgeon  who  was  some  time  at  Goru,  on  the  coast  of  Africa,  tells  me  that  the  natives  use 
in  these  fevers,  with  very  good  success,  a drink  prepared  by  macerating  in  water  a fruit  of  the 
plum  kind,  that  grows  there  in  great  plenty. ”f 

Lime  was  found  by  Maebride  to  prevent  but  not  remove  putrefaction.  Animal  fluids,  he 
observes,  will  remain  for  a long  time  without  putridity  if  kept  from  the  air.  He  says  that  astrin- 
gent mineral  acids  and  ardent  spirits  “not  only  absorb  the  matter  from  the  putrescent  substance, 
but,  likewise,  crisp  up  its  fibres,  and  thereby  render  it  so  hard  and  durable  that  no  change  of 
combination  will  take  place  for  years.” 


NOTE  5.  DISINFECTION  AS  PRACTICED  IN  THE  HOSPITALS  OF  MALTA,  AND  IN  THE 

LEVANTINE  LAZARETTOES. 

Disinfection  has  been  practiced  in  the  hospitals  of  Malta  and  in  the  Levantine  lazarettoes 
from  an  early  and,  as  far  as  my  information  extends,  for  an  indefinite  period. 

The  plague  was  first  noticed  in  the  “Maltese  Annals”  in  1549,  A.  d.  ; in  1593  it  again 
appeared  ; in  1623  forty-six  persons  died  of  it,  and  in  1663,  it  reappeared,  when  only  twenty 
persons  fell  victims  to  it.  But  its  advent  in  1675  was  dreadful,  for  11,300  persons  died  of  this 
dreadful  malady.  For  one  hundred  and  thirty  years  Malta  was  free  from  plague,  when  it  broko 
out  with  fearful  violence  in  1813;  from  its  commencement  in  April,  1813,  to  its  termination  in 
September  of  the  same  year,  4486  deaths  took  place  in  the  island,  of  which  1223  occurred  in 
Valetta,  the  mortality  being  about  80  in  the  100  attacked.}  The  monthly  progress  is  shown  by  tho 
deaths  from  April  to  November,  viz. ; April,  3 cases ; May,  110  ; June,  800;  July,  1595  ; August, 
1042;  September,  674;  October,  211;  November,  53.  Maximum  of  tho  thermometer  during 
these  months  was  71°,  82°,  84°,  88°,  86°,  88°,  83°,  72°,  F.  Strong  winds  blew  during  part  of 
the  period,  particularly  in  July. 

The  progress  of  this  mortality  resembled  that  of  the  yellow  fever  in  America. 


* “Essay  on  the  Fermentation  of  Alimentary  Mixtures,”  pp.  1-4. 

f “ Essay  on  the  Respective  Powers  and  Manner  of  Acting  of  the  Different  Kinds  of  Antiseptics,” 
pp.  165-166. 

t“  History  of  the  British  Colonies,”  by  R.  Montgomery  Martin,  Vol.  v.  Possessions  in  Europe. 
London,  1835,  p.  192. 


33G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  process  of  expurgation,  at  Malta,  during  the  plague  or  other  pestilential  diseases,  con- 
sisted of  the  free  and  continual  admission  of  air  to  all  parts  of  the  house  and  furniture;  the 
removal  of  filth  of  every  species;  ablution  of  all  woodwork  by  a strong  lye  of  soap  water  and  the 
application  of  hot  lime  wash  to  all  the  walls,  from  the  cellar  to  the  garret;  taking  care  to  remove 
and  repair  all  loose  or  decayed  pieces  of  plastering;  all  the  drains,  etc.,  completely  emptied  of 
their  contents  and  thoroughly  cleansed;  the  clothing  and  furniture  most  minutely  cleansed,  and 
such  parts  as  are  not  susceptible  of  damage  from  water  submitted  to  copious  effusions,  and  even 
boiled  in  a strong  lye  when  practicable ; books  and  all  other  similar  articles  placed  in  the  open 
air,  on  terraces,  etc.,  and  every  decayed,  superfluous,  or  useless  article,  particularly  in  the  form  of 
bags,  cordage,  paper,  clothes,  hangings,  etc.,  destroyed. 

To  these  precautions  were  added  fumigations  of  various  kinds,  mineral  and  vegetable;  those 
from  the  mineral  acids  were  very  frequent'y  used  in  the  public  hospitals.  The  smoke  of  straw, 
dampened  with  water,  and  the  fumes  of  vinegar  were  a’so  very  frequent  means  of  fumigation  ; 
but  the  great  officinal  formula  of  the  Levantine  lazarettoes  is  as  follows  (it,  however,  was  princi- 
pally applied  to  goods,  letters,  etc.) : — 


Sulphur, six  pounds. 

Orpiment,  crude  antimony,  litharge,  cumin  seed,  euphorbium,  black 

pepper,  ginger,  of  each, four  pounds. 

Asafcetida,  cinnabar,  sal  ammoniac,  of  each, three  pounds. 

Arsenic, one  pound. 

All  reduced  to  a fine  powder,  to  which  is  added — 

Raspings  or  sawdust  of  pine  wood, six  pounds. 

Bran, fifty  pounds. 


This  most  offensive  and  penetrating  compound  and  efficient  antiseptic  and  disinfectant 
appears  to  have  been  long  in  use,  for  it  is  noticed  by  Dr.  Russell,  in  his  history  of  Aleppo.* 

In  the  burning  of  such  a compound  sulphurous  acid  and  arsenious  acid  would  necessarily  be 
evolved,  as  well  as  some  of  the  compounds  of  mercury,  and  it  is,  perhaps,  true  that  modern  sani- 
tary science  has  failed  to  discover  a more  effective  and,  at  the  same  time,  a more  offensive  disin- 
fectant. The  fumes  of  this  compound  must  have  been,  if  inhaled  to  any  great  extent,  destructive 
to  all  animal  life,  even  that  of  man.  The  exposure  of  the  clothing  to  the  night  air  was  sup- 
posed by  many  to  be  the  most  effectual  of  all  means  of  purification,  and  the  Turks  and  other 
inhabitants  of  the  Levant  place  the  most  implicit  confidence  in  its  efficacy,  which  they  attribute 
principally  to  the  operation  of  the  dew. 

Coins  and  other  articles  were  purified  by  passing  them  through  vinegar,  and  the  free  use  of 
oil  in  anointing  the  body  has  prevailed  from  time  immemorial,  in  the  Levant  and  East,  as  a 
means  of  protection  against  the  plague. 

The  method  of  disinfection  practiced  in  the  quarantine  stations  and  lazarettoes  of  the  South  of 
Europe  and  the  Levant  was  investigated  by  the  celebrated  John  Howardf  and  Dr.  Charles 
Maclean, J who  voluntarily  subjected  themselves  to  the  barbarous  restrictions  of  the  odious  quar- 
antine, and  the  barbarous  method  of  confinement  in  damp,  ill-ventilated  and  filthy  rooms  of  the 
lazarettoes,  and  the  more  important  facts  relating  to  disinfection  recorded  by  these  authors  are 
embraced  in  the  preceding  observations. 

In  order  to  obtain  the  best  information,  by  performing  the  strictest  quarantine,  John  Howard 
took  passage  for  Venice,  from  Smyrna,  in  a ship  with  a foul  bill.  He  thus  records  his 
experience: — 

“Contrary  winds  and  other  causes  made  this  a tedious  and  dangerous  voyage,  and  it  was  sixty 
days  from  the  time  of  leaving  Smyrna  before  I arrived  at  Venice.” 

“Here,  after  our  ship  had  been  conducted  by  a pilot- boat  to  her  proper  moorings,  a messenger 
came  from  the  health  office  for  the  captain;  and  I went  with  him  in  his  boat  to  see  the  manner  in 
which  his  report  was  made,  his  letters  delivered,  and  his  examination  conducted.  The  following 

*“  History  of  the  British  Colonies,”  by  R.  Montgomery  Martin.  Vol.  v,  pp.  194, 195. 

f“  An  account  of  the  principal  Lazarettoes  in  Europe;  with  various  papers  relating  to  the  Plague, 
together  with  further  observations  on  some  Foreign  Prisons  aud  Hospitals,  etc.”  By  John  Howard, 
D.  R.  s.,  Warrington,  1789. 

I “ Results  of  an  Investigation  respecting  Epidemic  and  Pestilential  Diseases;  including  Researches 
in  the  Levant  concerning  the  Plague."  By  Charles  Maclean,  m.d.  London,  1817  ; 2 vols. 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  337 


morning  a messenger  came  in  a gondola  to  conduct  me  to  the  new  lazaretto.  I was  placed,  with 
my  baggage,  in  a boat  fastened  by  a cord  ten  feet  long  to  another  boat  in  which  were  six  rowers. 
When  I came  near  the  landing  place,  the  cord  was  loosed,  and  my  boat  was  pushed  with  a pole  to 
the  shore,  when  a person  met  me,  who  said  he  had  been  ordered  by  the  magistrates  to  be  my 
guard.  Soon  after  unloading  the  boat,  the  sub-prior  came  and  showed  mo  my  lodging,  which  was 
a very  dirty  room,  full  of  vermin,  and  without  table,  chair  or  bed.  That  day  ami  the  next  morn- 
ing I employed  a person  to  wash  my  room;  but  this  did  not  remove  the  offensiveness  of  it,  or 
prevent  that  constant  headache  which  I had  been  used  to  feel  in  visiting  other  lazarettoes,  and 
somo  of  the  hospitals  in  Turkey.  This  lazaretto  is  chiefly  assigned  to  Turks  and  soldiers,  and  the 
crews  of  those  ships  which  have  the  plague  on  board.  In  one  of  the  enclosures  was  the  crew  of 
a Ragusian  ship,  which  had  arrived  a few  days  before  me,  after  being  driven  from  Ancona  and 
Trieste.  My  guard  sent  a report  of  my  health  to  the  office,  and  on  the  representation  of  our 
consul,  I was  conducted  to  the  old  lazaretto,  which  is  nearer  the  city.  Having  brought  a letter 
to  the  Prior  from  the  Venetian  ambassador  at  Constantinople,  I hoped  now  to  have  had  a comfortable 
lodging.  But  I was  not  so  happy.  The  apartments  appointed  me  (consisting  of  an  upper  and  a 
lower  room)  were  no  less  disagreeable  and  offensive  than  the  former.  I preferred  lying  in  the 
lower  room,  on  a brick  floor,  where  I was  almost  surrounded  with  water.  After  six  days,  however, 
the  Prior  removed  me  to  an  apartment  in  some  respects  better,  and  consisting  of  four  rooms. 
Here  I had  a pleasant  view;  but  the  rooms  were  without  furniture,  very  dirty,  and  no  less  offen- 
sive than  the  sick  wards  of  the  worst  hospital.  The  walls  of  my  chamber,  not  having  been 
cleansed  probably  for  half  a century,  were  saturated  with  infection.  I got  them  washed  repeatedly 
with  boiling  water,  to  remove  the  offensive  smell,  but  without  effect.  My  appetite  failed,  and  I 
concluded  I was  in  danger  of  the  slow  hospital  fever.  I proposed  whitewashing  my  room  with 
lime  slaked  in  boiling  water,  but  was  opposed  by  strong  prejudices.  I got,  however,  this  done  one 
mornjpg,  through  the  assistance  of  the  British  Consul,  who  was  so  good  as  to  supply  me  with  a 
quarter  of  a bushel  of  fresh  lime  for  the  purpose.  And  the  consequence  was,  that  my  room  was 
immediately  rendered  so  sweet  and  fresh  that  I was  able  to  drink  tea  in  the  afternoon,  and  to  lie  in 
it  the  following  night.  On  the  next  day  the  walls  were  dry  as  well  as  sweet,  and  in  a few  days  I 
recovered  my  appetite.  Thus,  at  a small  expense,  and  to  the  admiration  of  the  other  inhabitants 
of  this  lazaretto,  I provided  myself  and  successors  an  agreeable  and  wholesome  room,  instead  of 
a nasty  and  contagious  one. 

“ Over  the  gateways  of  two  large  rooms  or  warehouses  was  carved  in  stone  the  images  of  three 
saints  ( San  Sebastiano,  San  Marco,  and  San  Rocco),  reckoned  the  patrons  of  this  lazaretto. 
Formerly,  when  persons  who  had  the  plague  wore  brought  from  the  city,  they  were  put  into  one 
of  these  rooms  for  forty  days,  and  afterward  into  the  other  for  the  same  time,  before  they  were 
discharged.”  John  Howard  adds,  in  a note : “ Many  of  the  windows  in  these  rooms,  and  also 
in  some  other  ancient  pest-houses  which  I have  seen,  are  now  bricked  up.  This  shows  that  in 
the  last  century  physicians  were  sensible  of  the  importance  of  fresh  air  and  a free  circulation  of 
it  in  sick  wards.  A different  practice,  particularly  in  the  smallpox  and  the  gaol-fever,  was  after- 
ward adopted  by  medical  gentlemen;  but  we  seem  now  to  be  returning  to  the  ancient  and  more 
i salutary  practice.  Formerly,  also,  it  seems  probable  that  men  did  not  entertain  these  absurd 
prejudices  against  the  free  use  of  water  in  washing  themselves  and  their  rooms,  which  are  now 
prevalent;  for  in  several  of  the  old  pest-houses  I have  observed  the  marks  of  a greater  attention 
to  the  means  of  gaining  plenty  of  water  than  has  been  thought  necessary  in  many  of  the  hospitals, 
built  within  these  fifty  years.”*' 

The  health  office  of  Venice  was  instituted  by  decree  of  the  Senate,  in  the  year  1448,  in  the 
midst  of  a very  destructive  pestilence,  and  afterward  confirmed  and  regulated  by  subsequent 
decrees,  till  reduced  to  the  order  in  which  it  stood  at  the  time  of  the  visit  of  John  Howard,  in  1785. 

NOTE  6.  HYDROCHLORIC  ACID  (MURIATIC  ACID),  NITROUS  ACID,  NITRIC  ACID,  PEROX- 
IDE OF  NITROGEN,  BINOXIDE  OF  NITROGEN  AND  CHLORINE  AS  DISINFECTANTS. 

An  essay  recommending  nitrate  of  potash  in  ventilation  received  the  recommendation  of  the 
Academy  of  Dijon  in  1767.  Dr.  Robert  Angus  Smith  suggests  that  when  this  substance  was  used 
in  ventilation  the  saltpetre  was  heated,  in  which  case  it  would  give  off  oxygen  gas,  which  at  first 

* An  account  of  the  Principal  Lazarettoes  in  Europe,  etc.,  pp.  10-12. 

Vol.  IV — 22 


338 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


is  very  pure;  afterward  nitrogen  comes  off,  and  then  the  salt  itself,  or,  at  least,  the  base,  is  car- 
ried into  the  air,  causing  a very  stifling  sensation.  The  oxygen,  however,  would  bo  valuable. 
This  plan  was  remarkable  as  having  been  tried  beforo  the  discovery  of  oxygen,  which  was  in 
1774. 

Guyton-Morveau  * made  a valuable  and  practical  advance  in  1773,  when  he  proposed  fumiga- 
tion with  muriatic  acid  vapors  as  a mode  of  disinfecting  hospitals;  but  the  acid  fumes  of  burning 
sulphur  had  been  used  in  Greece  and  Rome,  for  the  arrest  of  pestilence,  two  thousand  years 
before,  and  this  latter  agent  is  far  superior  to  muriatic  acid  as  a disinfectant.  The  Chancellor  of 
the  Legion  of  Honor,  writing  to  him  in  the  name  of  the  Emperor  Napoleon,  in  1805,  says: 
“ Europe  and  America  know  that  since  1773  you  have  employed  your  discovery  of  the  applica- 
tion of  muriatic  acid  fumes  to  arrest  the  effects  of  contagious  and  direful  diseases.”  He  obtained 
for  it  the  brevet  of  an  officer  of  the  Legion  of  Honor. 

The  Danish  method  of  fumigation  is  by  the  use  of  muriatic  acid ; common  salt  may  be  used 
by  pouring  sulphuric  acid  on  it,  without  heat,  and  nitric  acid  may  be  used,  but  the  products  are 
different. 

The  use  of  muriatic  acid  by  Guyton-Morveau,  in  1773,  has  justly  been  regarded  as  the  begin- 
ning of  acid  fumigation,  leaving  out  the  ancient  use  of  vinegar  and  of  sulphurous  acid. 

Chlorine  gas  was  discovered  by  Scheele,  in  1774,  and  while  we  cannot  go  to  the  ancients  for 
its  history,  it  has,  nevertheless,  been  supposed  that  the  ancient  Egyptians  used  it,  as  they  evi- 
dently obtained  nitric  acid  from  the  saltpetre,  and  this  must  have,  in  their  experiments,  been 
mixed  with  common  salt,  thus  giving  nitrous  gases  and  chlorine. 


NOTE  7.  EXPERIMENTS  AND  INVESTIGATIONS  ON  THE  MEANS  OF  PURIFYING  INFECTED 
AIR,  OF  PREVENTING  CONTAGION  AND  ARRESTING  ITS  PROGRESS  BY  FUMIGATION 
WITH  THE  MURIATIC  ACID,  INSTITUTED  BY  L.  B.  GUYTON-MORVEAU,  1773.  . 

The  employment  of  muriatic  acid  for  the  purification  of  vitiated  air  seems  first  to  have  been 
suggested  by  Dr.  James  Johnstone,  of  Worcester,  so  early  as  1758,  in  a Treatise,  entitled  “An 
Historical  Dissertation  on  the  Malignant  and  Epidemical  Fever  which  prevailed  at  Kidder- 
minster in  1756;  ” but  it  is,  indisputably,  to  M.  Morveau  that  the  medical  profession  is  indebted 
for  having  fully  established  its  efficacy  by  a variety  of  well-conducted  and  decisive  experiments. 
These  and  other  instances,  in  which  acid  fumigations  were  employed  with  the  greatest  success, 
seem  evidently  to  have  suggested  the  experiments  of  Dr.  Smith  with  the  nitric  acid  vapor,  on 
board  the  Union  Hospital  ship  at  Sheerness,  in  the  year  1795. 

The  questions  which  prompted  his  experiments  have  thus  been  stated  by  Guyton-Morveau: 
“Tho  most  mournful  events  incessantly  recall  to  our  attention  the  effect  of  contagion.  The  bare 
mention  of  this  word  presents  the  image  of  the  most  dreadful  of  all  the  evils  which  afflict 
humanity.  The  sword  blunts  its  edge  in  the  body  which  it  pierces;  poison  remains  inactive  in 
the  organ  which  it  has  deprived  of  sensation  ; fire,  removed  from  its  aliment,  dies  of  itself;  but 
contagion  derives  additional  force  from  the  number  of  its  victims. 

“ What,  then,  is  the  nature  of  those  invisible  corpuscles  which,  like  organic  beings,  possess  the 
power  of  reproduction,  and  of  assimilating  to  their  own  essence  everything  with  which  they  come 
in  contact,  and  which  seem  to  assume  life  but  for  tho  purpose  of  propagating  death  t Is  their 
composition  sufficiently  powerful  to  resist  tho  force  of  tho  chemical  agents  which  destroy  almost 
simultaneously  the  equilibrium  of  tho  elements  in  animate  as  well  as  inanimate  matter  ? ” 

Tho  sepulchral  vaults  of  the  principal  church  at  Dijon  having  been  entirely  filled,  in  conse- 
quence of  tho  winter  of  1773,  which  froze  the  ground  of  the  common  cemetery  to  such  a depth 
that  it  could  not  be  opened,  orders  were  given  to  remove  the  bodies  from  the  subterranean 
repositories.  It  was  conceived  that  sufficient  precaution  had  been  taken  by  throwing  in  some 
quicklime,  without  even  furnishing  a vent  for  the  putrid  effluvia,  or  suspecting,  what  ought  to 
have  been  anticipated  from  the  experiments  of  Macbride,  that  lime,  though  it  prevents  the 
process  of  putrefaction,  tends  only,  when  employed  at  a certain  stage  of  that  process,  to  accelerate 
the  evolution  of  its  products.  The  infection  of  the  air  soon  became  so  insupportable  that  it 
was  found  necessary  to  shut  up  the  church. 

* “Traite  des  Moyeus  de  Desinfecter  l’Air,  de  prevenir  la  Contagion,  et  d’eu  arr6ter  le  ProgrDs,” 


1805. 


SECTION  XV — TOBLIC  AND  INTERNATIONAL  HYGIENE.  339 


Unsuccessful  attempts  had  been  made  to  purify  the  air  by  the  detonation  of  nitre;  by  fumiga- 
tions of  vinegar;  by  burning  a variety  of  perfumes  and  odoriferous  herbs,  storax,  benzoin,  etc., 
and  by  sprinkling  the  pavements  with  a large  quantity  of  anti-pestilential  vinegar,  known  under 
the  name  of  “the  vinegar  of  the  four  thieves.”  The  odor  of  the  putrid  effluvia  was  merely 
masked  for  a moment  by  these  operations,  and  soon  reappeared  with  its  former  activity,  spreading 
to  the  neighborhood,  when  the  symptoms  of  a contagious  fever  began  to  appear.  At  this  period 
Guyton-Morveau  was  consulted  on  the  means  of  destroying  the  source  of  the  distemper. 

Guyton-Morveau  at  once  directed  his  attention  to  the  muriatic  acid,  the  very  diffusible 
vapors  of  which  might  seize  the  ammonia,  which  he  regarded  as  the  vehicle  of  the  fetid  mias- 
mata, and  thus  leave  the  latter  to  subside  by  their  own  gravity.  He  proposed,  therefore,  to  make 
trial  of  fumigation  with  the  muriatic  acid,  as  a means  of  purification.  It  was  accordingly  exe- 
cuted in  the  evening  of  the  6th  of  March,  1773,  with  six  pounds  of  common  salt,  and  two  pounds 
of  concentrated  sulphuric  acid.  The  whole  was  put  into  a capacious  bell-glass,  inverted  and 
placed  on  a bath  of  cold  ashes,  which  were  gradually  heated  by  means  of  a large  chafing  dish.* 

The  next  day,  the  church  being  wholly  thrown  open  for  admission  of  fresh  air,  not  the  slight- 
est vestige  of  any  offensive  odor  remained.  Four  days  after  service  was  performed  in  it  as  usual, 
without  any  danger,  or  even  the  least  apprehension. 

Another  event  furnished  occasion  to  Guyton-Morveau  for  a second  trial  of  this  process: 
Toward  the  end  of  the  same  year,  1773,  the  jail-fever,  which  is  known  to  be  of  the  same  nature 
with  the  hospital  fever,  had  been  carried  into  the  jails  of  Dijon  by  some  prisoners  removed  from 
.another  part  of  the  country.  Thirty-one  persons  had  already  sunk  under  it,  and  the  contagion 
continued  to  make  the  most  alarming  progress.  The  effect  of  the  fumigation  practiced  a few 
months  before,  in  the  church  of  St.  Stephen,  was  recollected,  and  Guyton-Morveau  was  requested 
to  superintend  the  execution  of  a similar  process,  which  was  accordingly  performed,  with  the 
greatest  success.  M.  Maret,  secretary  of  the  late  Academy  of  Sciences  at  Dijon,  inserted  an 
account  of  it  in  the  Journal  de  Physique,  of  January,  1774,  p.  73.  A singular  circumstance 
occurred  in  this  instance,  which  served  to  undeceive  those  who  regarded  fire  as  the  most  effectual 
purifier.  Such  was  the  virulence  of  the  infection  in  a particular  cell,  that  no  person  could 
approach  the  entrance  without  suspecting  that  one  of  the  dead  bodies  had  been  left  behind. 
This  was  the  unanimous  opinion  of  all  who  were  present  when  Guyton-Morveau  first  visited  it  : 
and  it  was  generally  known  that  even  subsequently  to  that  time  three  bundles  of  straw  had  been 
burnt  in  it,  the  traces  of  which  were  visible  on  the  walls,  the  archway  and  the  gate,  which  was 
of  iron.  The  day  after  the  fumigation,  in  which  he  employed  about  fifteen  decagrammes  only  of 
common  salt,  and  five  of  sulphuric  acid,  the  putrid  odor  was  so  completely  removed  that  a student 
of  surgery  offered  to  stop  in  it  for  the  night. 

In  1774,  an  almost  general  epizootic  distemper  ravaged  the  South  of  France.  M.  Vicq-d’ 
Azyr  circulated  some  directions  with  respect  to  the  manner  of  purifying  the  villages  and  stables; 
among  these  he  takes  notice  of  fumigation  with  the  muriatic  acid.  “ The  object  to  be  proposed,” 
says,  M.  Vicq-d’  Azyr,  “ is  to  destroy  the  miasmata  with  which  the  atmosphere  and  the  walls  are 
impregnated,  and  to  admit  a free  circulation  of  air  into  the  stables.  Those  who  wish  to  effect 
these  purposes  must  begin  with  putting  a quantity  of  ashes,  or  sand,  into  an  earthen  pan.  In 
the  midst  of  this  bath  should  be  placed  a glass  vessel  filled  with  culinary  salt;  and  the  whole 
must  then  be  heated.  A quantity  of  vitriolic  (sulphuric  acid),  must  bo  gradually  poured  upon 
the  salt.  The  same  process  should  be  performed  at  both  ends  of  the  stable,  if  it  bo  somewhat 
large.  The  white  fumes  which  ascend  will  then  become  very  active.” 

With  reference  to  aromatic  substances,  M.  d’  Azyr  says,  “in  burning,  only  an  agreeable  is 
substituted  for  a fetid  odor.  They  merely  deceive  the  organ  of  smell,  but  do  not  destroy  the 
putrid  miasmata.  The  saline  vapors  possess  the  latter  advantage,  and  on  that  account  ought  to 
be  preferred.” 

In  the  following  year,  two  productions  by  M.  de  Montigny,  which  had  the  approbation  of  tho 
Academy  of  Sciences,  were  published  together  in  the  same  volume,  by  order  of  the  Government. 
The  one  of  them  was  entitled,  “ Instructions  and  advice  to  tho  inhabitants  of  tho  Southern 


* The  details  of  the  process  of  Guyton-Morveau  were  described  with  considerable  accuracy  in  the 
Journal  de  Physique  of  that  year,  Vol.  I,  p.  436,  under  the  title  of  “ A new  method  of  purifying  coin- 
1 stately,  and  in  a very  short  space  of  time,  a mass  of  contaminated  air.” 


340 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Provinces  respecting  the  putrid  and  pestilential  malady  which  proves  so  destructive  to  cattle;  " 
the  other  “ Advico  to  the  people  of  tho  provinces  into  which  the  contagion  has  penetrated.”  Both 
of  them  equally  recommend  tho  method  of  M.  do  Morveau,  of  destroying  infection. 

In  1780,  the  Academy  of  Sciences  was  consulted  by  the  Government  on  the  means  of  correct- 
ing tho  insalubrity  of  prisons,  and  appointed  a committee  to  investigate  the  matter,  composed 
of  MM.  Duhamel,  Do  Montiguz,  Leroi,  Tenon,  Tillot,  and  Lavoisier.  Ono  of  their  objects  was 
to  comparo  and  appreciate  tho  different  known  methods  of  purifying  infected  air.  In  tho  report 
of  this  Commission,  on  the  17th  of  March,  1780,  printed  in  the  volume  of  memoirs  for  that  year, 
they  express  tho  opinion  that  “ Another  precaution  which  we  think  it  our  duty  to  recommend,  and 
which  will  contribute  more  than  anything  to  the  salubrity  of  prisons,  is  once  a year  to  destroy 
contagion  by  tho  method  successfully  employed  by  M.  de  Morveau.  It  consists  in  disengaging 
in  those  places  which  it  is  proposed  t")  purify  a considerable  quantity  of  marine  acid  in  a state  of 
vapour,  etc.  The  vitriolic  acid  disengages  that  of  the  sea  salts,  which  last,  rising  in  the  form  of 
a white  vapour,  diffuses  itself  over  the  chamber  and  neutralizes  the  putrid  miasmata.”  * 

It  might  have  been  supposed  that,  supported  by  such  respectable  authorities,  this  method  would 
have  been  practiced  when  the  first  symptoms  of  contagion  rendered  it  necessary;  but  during  the 
twelve  subsequent  years  it  was  wholly  neglected;  the  lazarettoes  were  abandoned  to  the  usual 
routine  of  aromatic  fumigations,  and  the  hospitals  and  prisons  to  the  most  deplorable  neglect,  at 
the  time  when  tho  crowd  of  patients  augmented  the  ordinary  contagion,  which  began  to  prove 
fatal  in  many  instances,  even  to  the  attendants  of  the  sick. 

In  the  second  year  of  the  Republic,  1794,  in  consequence  of  the  multitude  of  persons  infected 
with  fever,  and  of  the  wounded  which  it  was  necessary  to  receive  into  the  military  hospitals  of  the 
interior,  hospital  fever  prevailed  to  a great  and  alarming  extent,  and  many  eminent  physicians 
fell  victims  to  the  contagion.  M.  Guyton-Morveau  therefore  proposed  to  the  Convention  that 
instructions  should  be  drawn  up  and  published  respecting  the  means  of  arresting  the  progress  of 
the  contagion.  They  therefore  passed  the  following  decree  : “ The  Executive  Council  shall  cause 
to  be  drawn  up,  without  delay,  by  the  Board  of  Health,  detailed  instructions  respecting  the  me- 
chanical and  chemical  means  of  preventing  the  progress  of  infection  in  the  hospitals,  and  of  purify- 
ing the  air  from  the  mephitic  vapors  or  putrid  miasmata,  with  which  it  may  be  charged.  These 
instructions  shall  be  printed  and  sent  by  the  Minister  of  War  to  all  the  military  hospitals,  by 
the  Minister  of  Marine  to  the  naval,  and  by  the  Minister  of  the  Interior  to  the  civil  hospitals. 
Guyton-Morveau  is  charged  with  the  superintendence  of  the  matter.” 

The  Board  of  Health,  after  a series  of  experiments,  conducted  by  a committee  of  its  members, 
at  the  hospitals  of  St.  Cyr,  Franciade  and  Gros  Caillon,  reported: — 

“The  results  of  these  experiments  incontestably  proves  that  the  proposed  method  of  purifying 
hospitals  by  the  muriatic  acid  gas,  may  be  practiced  without  inconvenience,  and  xcith  the  greatest 
ailvantages,  in  full  as  well  as  in  empty  wards  ; observing  always  to  disengage  in  the  former  a 
smaller  proportion  of  gas.” 

This  conclusion  of  the  Board  of  Health,  delivered  in  the  instructions  approved  by  the 
Provisional  Executive  Council  on  the  seventh  ventose,  year  two,  was  sent  by  the  Minister  of  War 
to  the  military  commissaries,  to  the  officers  of  health,  and  those  employed  in  the  military  hospi- 
tals, with  injunctions  to  carry  into  execution  the  processes  prescribed. 

That  these  recommendations  by  tho  Board  of  Health  and  Provisional  Executive  Council  pro- 
duced but  imperfect  and  unsatisfactory  results,  is  evident  from  the  following  statement  of  Guyton- 
Morveau,  the  discoverer  of  the  method  of  fumigation  by  muriatic  acid: — 9 

“What  was  the  result  of  opinions  so  decisive,  and  orders  so  precise?  It  is  with  regret  I 
observe  that  occasions  on  which  tho  process  might  have  been  employed  have  repeatedly  occurred, 
of  a nature  to  arouse  the  attention  of  tho  officers  of  health  to  their  own  safety;  yet  most  of  them 
remain  ignorant  both  of  tho  process  of  fumigation  and  of  its  salutary  effects.  Citizen  Chaussier, 
indeed,  Professor  of  Anatomy  in  the  Medical  School,  practiced  it  with  success  in  ono  of  tho  mili- 
tary hospitals  at  Dijon,  of  which  ho  had  tho  direction.  It  was  also  employed,  when  I was  in  the 
army  of  the  Saome  and  Meuse,  in  purifying  some  hospitals  in  Belgium,  which  the  Austrians 
had  left  in  a very  foul  state.  But  these  were  the  only  instances  of  the  execution  of  tho  instruc- 
tions which  have  come  to  my  knowledge,  when  I very  recently  learned  from  the  reports  made  by 


* Memoir  of  the  Royal  Academy  of  Sciences  for  1780,  p.  421. 


SECTION  XV — ITJBLIC  AND  INTERNATIONAL  HYGIENE.  341 


the  Board  of  Health  to  the  Minister  at  War  that  the  process  prescribed  in  the  instructions  was 
practiced  in  the  course  of  the  epidemio  disease  with  which  the  Army  of  the  Western  Pyrenees 
had  been  attacked,  in  the  year  throe.  It  is  also  in  consequence  of  the  solicitude  which  the  minister 
has  felt  on  this  subject,  that  T have  learned  that  the  process  was  recommended  and  followed  in  the 
destructive  disorder  which  last  year  (year  seven)  made  such  ravages  in  the  army  of  Italy,  and 
the  Southern  department.  Thus  we  have  received  notone  attestation,  not  one  relation,  no  official 
publication,  and  not  even  a simple  notice  respecting  the  practice  of  acid  fumigation  and  its  results 
in  different  circumstances.” 

The  mortality  occasioned  at  Genoa  by  the  contagious  malady  which  raged  in  that  city  in 
1S00,  as  well  as  the  disposition  on  the  part  of  the  French  Government  to  enforce  by  its  authority 
the  introduction  of  acid  fumigations  into  the  military  hospitals,  afforded  new  motives  to  M.  Guy- 
ton-Morveau  for  resuming  his  inquiries  on  this  subject,  and  gave  rise  to  an  important  publica- 
tion,* in  which  he  gives  a history  of  acid  fumigations,  the  results  obtained,  and  the  experiments 
illustrating  their  effects  and  modes  of  application. 

At  the  time  when  the  epidemic  disease  of  Genoa  raged  in  its  utmost  violence,  a malady,  differ- 
ent in  character,  but  not  less  dreadful,  broke  out  at  Cadiz,  and  spread  with  such  rapidity  as  to 
threaten  the  whole  of  Andalusia. 

The  account  of  the  epidemic  disease  of  Genoa,  published  by  Doctor  Rasori,f  in  which  he 
regarded  the  disease  as  true  hospital  fever, \ appeared  to  Guyton-Morveau  important  conclusions 
in  favor  of  anti-contagious  fumigations. 

Although  Rasori  held  that  the  cause  of  the  malady  of  Genoa,  as  well  as  that  which  preceded  it 
at  Nizza,  was  some  foreign  matter  introduced  into  the  system  in  an  unknown  manner,  and  that 
it  originated  in  the  hospitals,  and  from  the  exhalations  from  a number  of  dead  bodies  improperly 
interred,  he  does  not  indicate  any  measures  for  the  destruction  of  the  putrid  and  contagious 
effluvia.  In  fact,  he  states  that  one  of  the  conclusions  arrived  at  by  the  Conference  of  the  Board  of 
Health  and  Physicians  of  Genoa  was  that,  “ instead  of  applying  ourselves  to  indicate  the  ordinary 
and  commonly  ineffectual  preventatives,  it  was  necessary  to  think  at  first  of  deciding  upon  a 
general  method  of  cure.”  The  measures  recommended  by  the  physicians  of  CadizjJ  consisted 
simply  in  cleansing  the  sewers,  the  interment  of  the  dead  without  the  precincts  of  the  city, 
watering  the  streets,  lighting  in  the  streets  and  squares  large  fires  of  green  fir,  explosions  of 
small  quantities  of  gunpowder,  and  the  sprinkling  of  the  inside  of  the  houses  with  vinegar  and 
aromatic  plants. 

This  was  not  the  case  at  Seville,  to  which  place  the  yellow  fever  had  extended,  and  where  it 
made  the  most  alarming  progress.  Acid  fumigations  were  there  employed  with  success.  M.  Ch. 
Gimbernat,  in  a letter  addressed  to  Guyton-Morveau,  on  the  18th  of  January,  1801,  says  : “The 
instructions  which  I communicated  respecting  the  manner  of  performing  fumigations  with  the 
muriatic  and  nitric  acids,  have  produced  the  happiest  effects  in  stopping  the  progress  of  the  con- 
tagion in  Andalusia. 

“ Unfortunately,  prejudices  for  some  time  retarded  the  application  of  this  powerful  remedy. 
But  at  length  the  zeal  and  information  of  two  medical  men,  Queralto  and  Sarrais,  sent  by  the 
i Government  to  Seville  with  the  necessary  orders  and  authority  to  practice  the  acid  fumigations 
as  profusely  and  generally  as  the  extent  of  the  contagion  required,  produced  the  most  prompt 
and  fortunate  success.  Commissary  Sarrais,  one  of  the  ablest  physicians  of  Spain,  was  seized 
with  the  contagion  on  the  very  day  of  his  arrival  at  Seville,  and  died  on  the  following  day. 

“ The  reports  made  by  Queralto  to  the  Government  attest  that  it  is  to  the  acid  fumigations  we 
i owe  the  extinction  of  a malady  which  threatened  to  throw  the  whole  nation  into  mourning.” 

It  is  evident,  from  the  preceding  facts,  that  fumigations  with  muriatic  and  nitric  acids  wore 
; employed  for  the  arrest  of  yellow  fever  in  Spain  as  early  as  1800. 

The  following  directions  were  given  by  Guyton-Morveau  for  the  uerformance  of  his  method 
1 of  fumigation  with  muriatic  acid: — 

*‘‘A  Treatise  on  the  Means  of  Purifying  Infected  Air,  of  Preventing  Contagion  and  Arresting  its 
Progress.”  By  L.  B.  Guyton-Morveau,  Member  of  the  National  Institute  of  France,  etc. 

f'Storia  della  Febre  Epidemica  di  Genova  negli  anni,  1799-1800.”  Milan,  9th  year;  in  8vo,  222  pages. 

I “ La  Nostra  Febre  Epidemica  e della  Stessa  Indole  della  vera  Nosocomiale.”  Storia,  etc.,  p.  91. 

% “ An  Account  of  the  Epidemic  Diseases  of  Cadiz.”  Translated  into  French,  from  the  Spanish,  by 
F.  F.  Bliss,  etc.,  p.  10. 


342 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


“ When  it  is  intended  to  purify  the  air  in  the  chambers  of  infirmaries,  the  wards  of  hospitals, 
in  close  places  after  exhumations,  where  animal  matters  have  been  allowed  to  putrefy,  or  where 
some  individuals  have  died  of  epidemic  or  contagious  maladies,  and  which  are  not  inhabited,  we 
place  a chafing-dish  in  the  centre,  and  on  it  an  iron  pot  ha'f  filled  with  silieious  sand  or  ashes. 
On  this  bath  must  then  be  placed  a large  glass  vessel  containing  muriate  of  soda  ( common  salt), 
and  when  this  begins  to  be  heated  sulphuric  acid  {oil  of  vitriol  of  commerce)  should  be  poured  on 
the  salt ; after  which  the  doors  and  windows  should  be  kept  as  closely  shut  as  possible  for  seven 
or  eight  hours. 

“ To  determine  the  quantity  of  materials  necessary  for  the  intended  purpose,  let  us  suppose, 
for  example,  a lofty  ward  or  apartment  containing  twenty  beds ; it  would  require  of  common 
salt  thirty  decagrammes  (about  nine  ounces  six  drachms),  sulphuric  acid,  twenty-four  deca- 
grammes (about  seven  ounces  seven  drachms).  These  quantities  must  be  augmented  or  dimin- 
ished in  proportion  to  the  space  in  which  they  are  intended  to  act.  Experiments  have  demon- 
strated that  three  kilogrammes  of  salt  are  sufficient  to  completely  purify,  and  by  a single  fumiga- 
tion, the  air  in  a church  the  capacity  of  which  is  about  15,000  cubic  metres,*  or  about  2023  cubic 
toises.  A chamber  of  the  size  of  between  twenty-five  and  thirty  square  metres  will  require  no- 
more  than  ten  decagrammes  of  salt  and  eight  of  acid. 

“Such  is  the  method  in  which  fumigations  may  be  practiced  when  no  particular  considera- 
tion renders  it  necessary  to  restrain  either  their  duration  or  intensity,  and  where  it  is  intended 
they  should  at  once  produce  a complete  purification.  They  must,  however,  be  conducted  in  a very 
different  manner  in  places  which  are  inhabited,  where  it  is  often  necessary  to  carry  them  near 
to  the  beds  of  the  sick,  and  where  they  must  be  repeated  at  certain  intervals  in  proportion  to  the 
more  or  less  rapid  reproduction  of  the  contagious  emanations. 

“ In  very  extensive  wards,  instead  of  a large  apparatus,  several  small  ones  should  be  employed 
at  different  points,  each  containing  four  or  five  decagrammes  of  salt,  upon  which  may  be  poured 
two-thirds  of  the  weight  of  sulphuric  acid ; since  it  would  be  altogether  useless  to  effect  the  entire 
decomposition  of  the  salt,  the  vapors  which  are  first  disengaged  being  sufficient  for  our  purpose. 
In  this  case,  the  method  employed  by  Citizen  Chaussier  in  a large  military  hospital,  which  we 
have  already  mentioned,  is  very  advantageous.  He  causes  the  apparatus  containing  the  salt  to 
be  carried  round  the  apartment,  upon  which  the  acid  is  poured  by  degrees,  so  that  the  extrication 
of  the  vapors  may  bo  made  to  take  place  at  any  point  and  in  any  quantity  that  is  judged  neces- 
sary, without  the  smallest  inconvenience  to  the  sick.  ” | 

NOTE  8.  METHOD  OF  FUMIGATION  ADOPTED  IN  SPAIN. 

The  mode  of  fumigation  practiced  in  Spain  near  the  close  of  the  last  century,  for  correcting 
the  insalubrity  of  the  air,  consisted  in  disengaging  muriatic  acid  gas,  by  means  of  sulphuric  acid, 
in  the  manner  directed  by  Guyton-Morveau  in  1773.  In  the  Journal  of  Agriculture  and  Art » 
( Semanario  de  Agricultura  y Artes  dirigido  a los  Parvoos),  for  1797,  a description  is  given  of 
this  method,  under  the  article  “ Domestic  Medicine.” 

It  is  stated  that  it  continued  to  be  used  with  success  at  Madrid;  and  further,  that  experience 
had  proved  that  it  might  be  employed  in  wards  when  persons  were  present,  even  without  any 
inconvenience  or  danger  to  the  sick,  performing  it  with  small  quantities  at  a time  and  frequently 
repeating  the  process.  This  method  of  fumigation  is  recommended  as  very  beneficial  in  all  cases 
of  pestilential  fevers,  epidemic  and  epizootic  distempers.  Tho  process  even  appears  to  have 
become  so  common  that  it  was  considered  of  importance  to  derive  some  advantage  from  the  salt 
remaining  in  the  vessels. 

In  the  Dutch  receipts,  used  not  much  after  the  time  of  the  discovery  of  chlorine  gas,  the  aeid 
fumigation  was  obtained  by  pouring  sulphuric  or  nitric  acid  on  common  salt;  the  first  gives 
muriatic  aeid  and  the  second  chlorine. 

Muriatic  acid  destroys  vegetation  and  attacks  with  violence  metallic  substances,  and  is  irri- 
tating to  the  lungs  of  animals  and  poisonous  when  inhaled  in  any  considerable  quantities;  it  is 

not  a good  practical  antiseptic,  and  is  inferior  iu  its  disinfecting  properties  to  chlorine  and  nitrous 

acid. 


* A metre  is  3 feet,  1 1 lines,  of  the  old  French  measure, 
t “ Treatise  on  the  Means  of  Purifying  Infected  Air,  etc.,”  pp.  234-237. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  343 


Dr.  Carmichael  Smith  used  nitrous  fumes  at  Winchester,  in  1780,  and  afterward  in  the  Fleet, 
and  in  1802  the  British  Parliament  voted  him  £5000  for  his  method  of  acid  fumigation. 

The  nitrous  acid  fumes  were  tried  very  largely,  toward  the  close  of  the  last  century  and  the 
beginning  of  this,  in  the  hulks  and  prisons  where  Spanish,  French  and  Russian  prisoners  of  war 
were  confined.  * At  that  time,  so  rapidly  did  the  disease  (typhus  fever)  spread  in  the  confined 
spaces  where  so  many  men  were  kept,  that  the  efficacy  even  of  ventilation  was  doubted,  though 
there  can  be  no  question  that  the  amount  of  ventilation  which  was  necessary  was  very  much 
underrated.  Both  at  Winchester  and  Sheerncss  the  circumstances  were  most  difficult.  At  the 
latter  place  (in  1795),  in  the  hulk,  200  men,  150  of  whom  had  typhus,  were  closely  crowded 
together;  ten  females  and  24  men  of  the  crew  were  attacked;  three  medical  officers  had  died 
when  the  experiment  commenced.  After  the  fumigations,  one  attendant  only  was  attacked,  and 
it  appeared  as  if  the  disease  in  those  already  suffering  became  milder.  In  1797  it  was  again  tried 
with  success.”  Many  reports  were  made  on  the  subject  by  army  and  navy  surgeons.  It  was 
subsequently  largely  employed  on  the  continent,  f and  everywhere  seems  to  have  been  useful  in 
typhus  exanthematicus. 


NOTE  9.  EXPERIMENTS  ON  THE  PURIFICATION  OF  AIR  BY  FUMIGATIONS  WITH  NITROUS 
ACID  (NITRIC  ACID),  ACCORDING  TO  THE  METHOD  OF  DR.  CARMICHAEL  SMITH,  1780-1795. 

Dr.  Smith  first  used  nitrous  acid  fumigation  at  Winchester  in  1780,  and  published  several 
accounts.  From  a publication  entitled  “ An  Account  of  the  Experiments  made  at  the  Desire  of 
the  Lords  Commissioners  of  the  Admiralty,  on  board  the  ‘Union’  Hospital  Ship,  to  Determine  the 
Effect  of  the  Nitrous  Acid  in  Destroying  Contagion,  and  the  Safety  with  which  it  may  be 
Employed,  etc.,”  London,  1796,  Svo,  73  pages,  we  extract  the  following,  illustrating  his  method 
of  disinfection : — 

The  Lords  of  the  Admiralty  being  desirous  that  Dr.  Smith  should  send  some  person  on  board 
the  hospital  ship  “ Union  ” to  make  trial  of  fumigation  with  Nitrous  Acid,  the  Doctor  intrusted  the 
direction  of  the  experiment  to  Mr.  Menzies,  a surgeon  in  the  Royal  Navy,  so  that  the  report 
which  he  presented  is  an  exact  copy  of  the  journal  of  the  means  employed  by  him  to  arrest  the 
progress  of  the  contagion. 

Mr.  Menzies  set  out  from  London,  November  24th,  1795,  and  arrived  the  same  day  at  Sheer- 
ness. On  his  first  visit  to  this  hospital,  he  judged  that  it  would  be  difficult  to  obtain  conclusive 
results  from  his  experiments,  because  new  contagion  was  every  day  conveyed  from  the  Russian 
vessels.  Their  lower  and  middle  gun-decks  were  divided  into  wards  by  cross  partitions,  with  a 
free  communication  between  each.  The  sick  were  much  crowded  and  placed  without  order,  to 
the  number  of  nearly  200,  of  whom  about  150  were  in  different  stages  of  a malignant  fever, 
extremely  contagious,  as  appeared  evident  from  its  rapid  progress  and  fatal  effects.  From  the 
month  of  September,  when  the  Russian  sick  were  first  admitted,  eight  nurses  and  two  washer- 
women had  been  attacked  with  this  fever,  and  of  these  three  had  died.  About  twenty-four  of 
the  ship’s  company  had  likewise  been  ill  of  the  same  disorder,  and  of  these  a surgeon’s  mate  and 
two  marines  had  died.  In  short,  there  could  be  no  doubt,  from  the  evident  malignity  of  the 
fever,  that,  without  the  incessant  attention  and  activity  of  Mr.  Bassan,  to  whose  care  they  were 
intrusted,  it  would  have  proved  still  more  fatal. 

Mr.  Menzies  caused  to  be  brought  on  board  the  necessary  apparatus  and  material  for  fumiga- 
i tion.  These  consisted  of  a sufficient  quantity  of  fine  sand,  two  dozen  quart  earthen  pipkins,  as 
many  common  teacups,  together  with  some  slips  of  glass  to  be  used  as  spatulas,  and  a quantity 
' of  concentrated  sulphuric  acid  and  pure,  pulverized  nitre. 

On  the  26th  of  November  he  began  his  operations  by  causing  the  ports  and  scuttles  to  be  shut. 
The  sand,  which  had  been  previously  heated  in  iron  pots,  was  then  scooped  into  the  pipkins  by 
means  of  an  iron  ladle,  and  in  this  heated  sand,  in  each  pipkin,  a small  teacup  was  immersed, 
containing  half  an  ounce  of  concentrated  sulphuric  acid.  To  this,  after  it  had  acquired  a proper 
degree  of  heat,  an  equal  quantity  of  nitre  in  powder  was  gradually  added,  and  the  mixture 
stirred  with  a glass  spatula  till  the  vapor  was  disengaged  in  considerable  quantity.  The  pipkins 
were  then  carried  through  the  wards  by  tho  nurses  and  convalescents,  who  kept  walking  about 

* “An  Account  of  the  Experiments  made  at  the  desire  of  the  Lord  Commissioners  of  the  Admiralty.” 
By  J.  C.  Smith,  1796.  t Chevallier.  Traito  des  Disinfectants,  pp.  39,  40. 


344 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


with  them  in  their  hands,  and  occasionally  putting  them  under  the  cradles  of  the  sick,  and 
in  every  corner  where  foul  air  was  expected  to  lodge.  In  this  manner  the  fumigation  was 
continued  till  the  whole  space  between  decks  was  filled  with  the  vapor,  which  appeared  like 
a thick  haze. 

“I,  however,  proceeded,”  says  Mr.  Menzies,  “in  this  first  trial,  slowly  and  cautiously,  follow- 
ing with  my  eyes  the  pipkins  in  every  direction,  to  watch  the  effect  of  the  vapor  on  the  sick,  and 
observed  that  it  at  first  excited  a good  deal  of  coughing,  but  which  gradually  ceased  in  propor- 
tion as  it  became  more  generally  diffused  through  the  wards.  This  effect  appeared,  indeed,  to  be 
chiefly  occasioned  by  the  ignorance  of  those  who  carried  the  pipkins,  in  putting  them  sometimes 
too  near  to  the  faces  of  the  sick,  by  which  means  they  suddenly  inhaled  the  strong  vapor  as  it 
immediately  issued  from  the  cups. 

“In  compliance  with  Dr.  Smith’s  request,  the  body  clothes  and  bed  clothes  of  the  sick  were, 
as  much  as  possible,  exposed  to  the  nitrous  vapor  during  the  fumigation;  and  all  the  dirty  linen 
removed  from  them  was  immediately  immersed  in  a tub  of  cold  water,  afterward  carried  on  deck, 
rinsed  out  and  hung  up  till  nearly  dry,  and  then  fumigated  before  it  was  taken  to  the  wash  house, 
a precaution  extremely  necessary  in  every  infectious  disorder.  Due  attention  was  also  paid  to 
cleanliness  and  ventilation.  As  the  people  were  at  first  very  awkward  and  slow,  it  took  us  about 
three  hours  to  fumigate  the  ship.  In  about  an  hour  after,  the  vapor  having  entirely  subsided, 
the  ports  and  scuttles  were  thrown  open  for  the  admission  of  fresh  air.  I then  walked  through 
the  wards  and  plainly  perceived  that  the  air  of  the  hospital  was  greatly  sweetened,  even  by  this 
first  fumigation.”  Next  morning  the  ship  was  again  fumigated,  and  the  operation  was  performed 
in  the  course  of  an  hour.  The  sand  being  more  heated,  the  vapor  disengaged  itself  more  speedily, 
while  the  patients  suffered  no  other  inconvenience  but  a slight  coughing,  which  was  less  general 
than  on  the  preceding  day. 

Twelve  pijjkins  were  found  sufficient  for  fumigating  the  lower  deck,  ten  for  the  middle  gun- 
deck,  two  for  the  ship’s  company’s  bedroom,  two  for  the  marine’s  bedroom,  and  one  for  the 
washing  place,  in  all  twenty-seven  pipkins;  consequently  about  fourteen  ounces  of  the  sulphuric 
acid,  and  as  much  nitre,  was  expended  in  the  forenoon. 

In  the  evening,  as  every  place  was  so  close,  and  the  fresh  air  could  not  afterward  be  so  freely 
admitted,  it  was  not  thought  necessary  to  employ  so  many  pipkins,  so  that  little  more  than  half 
the  quantity  of  the  fumigating  materials  used  in  the  morning  was  generally  found  sufficient  for 
the  evening’s  fumigation. 

The  immediate  effect  of  this  process  in  destroying  the  offensive  smell  arising  from  so  many 
sick  crowded  together  was  now  very  perceptible  even  to  the  nurses  and  attendants,  who  were  no 
longer  afraid  of  approaching  the  cradles  of  the  infected,  so  that  the  latter  were  better  attended, 
while  a pleasing  gleam  of  hope  cast  its  cheering  influence  over  that  general  despondence  which 
was  before  evidently  pictured  on  every  countenance,  from  the  constant  dread  each  individual 
naturally  entertained  of  being  perhaps  the  next  victim  to  the  contagion. 

Mr.  Menzies  caused  these  fumigations  to  be  repeated  for  eight  days,  with  equal  success;  not 
only  was  there  no  inconvenience  felt,  but  he  observed  that  while  the  danger  of  infection  was 
removed,  the  malignity  of  the  disorder  was  diminished.  He  also  proposed  a useful  alteration  in 
the  position  of  the  necessaries,  of  which  it  was  not  possible  to  banish  the  putrid  effluvia  without 
perpetual  washings,  which  endangered  the  life  of  those  who  were  charged  with  the  troublesome 
office.  He  took  care  that  the  beds  of  those  who  were  discharged  from  the  hospital  should  be 
washed  with  the  diluted  muriatic  acid,  in  pursuance  of  the  instructions  of  Dr.  Smith. 

On  the  seventh  of  December,  Mr.  Menzies  resigned  to  Mr.  Bassan  the  care  of  continuing  the 
experiments.  Since  their  commencement  nono  of  the  attendants  or  ship’s  company  had  been 
soized  with  this  fever,  with  the  exception  of  one  nurse,  who  suffered  a slight  relapse  from  some 
imprudence;  and  none  of  the  patients  had  died.  It  was  therefore  manifest  that  the  process  had 
produced  the  happiest  effects,  and  that  it  might  be  employed  with  particular  advantage,  and  with- 
out any  inconvenience  or  danger  of  fire,  in  ships  where  many  people  were  crowded  together  within 
a narrow  compass. 

Annexed  to  this  journal  of  Mr.  Menzies  are  extracts  from  the  correspondence  of  Mr.  Bassan 
with  Dr.  Smith  and  Mr.  Menzies  concerning  the  effects  of  the  operations  which  the  Doctor  had 
intrusted  to  his  care;  in  these  it  is  noticed  that  only  one  sick  Russian  had  died  since  the 
commencement  of  the  fumigations  up  to  the  latter  part  of  December,  and  only  one  nurse  and 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  345 

one  marine  had  been  taken  ill  of  the  fever,  although  the  symptoms  wore  much  milder  than 
formerly. 

On  the  third  of  February,  Mr.  Bassan  writes  that  the  contagious  fever  had  entirely  ceased, 
and  that  no  person  had  been  seized  since  the  26th  of  December,  though  during  the  intermediate  space 
they  had  been  daily  receiving  patients  laboring  under  tho  same  putrid  petechial  fever  from  the 
Russian  ships.  In  short,  he  regarded  the  experiment  as  decisive,  and  proposed  continuing  to 
employ  the  same  acid  fumigation  for  the  purpose  of  destroying  the  alkaline  miasmata,  and  of 
purifying  the  air.  He  also  informed  Dr.  Smith  that  Captain  Senevin,  of  the  “ Pamet  Eustaphia,” 
of  74  guns,  had  assured  him  that  having  continued  the  fumigation  every  day  since  the  departure 
of  Mr.  Menzies,  he  had  no  longer  any  sick  on  board. 

Next  follows  a second  journal  of  Mr.  Menzies,  relating  some  new  trials  of  this  fumigating 
process,  made  on  board  some  ships  of  the  Russian  squadron  at  the  request  of  Admiral  Hannicoff. 

The  “ Pamet  Eustaphia”  was  first  pitched  upon  for  this  fumigation,  because  that  ship  had  sent 
moresiek  with  malignant  fever  to  the  hospital  than  all  the  rest  of  the  squadron.  Notwithstanding 
numerous  disadvantages  from  the  nature  of  the  ballast,  composed  of  sand  and  rock  earth,  the  nature 
of  the  clothing  of  the  Russian  sailors,  consisting  in  part  of  a sheepskin  great  coat  with  the  woolly 
side  inward,  and  from  the  crowded  condition  of  the  ship,  the  effect  of  the  first  fumigations  was  so 
perceptible  that  the  Russian  surgeons  were  inclined  to  continue  them.  Fumigations  were  also 
instituted  on  the  16th  of  December  on  board  the  “ Pimen,”  of  66  guns,  Captain  Colokolsoff,  when 
the  infection  had  reached  such  a height  that  communication  with  the  other  ships  was  forbidden; 
also  in  the  ship  “ Katvezan,”  and  the  frigate  “Revel,”  where  a malignant  fever  had  discovered 
itself. 

The  acid  fumigations  arrested  the  disease  on  these  ships. 

The  following  is  the  “ Certificate  of  Captain  Chichagof,  Commanding  Officer  of  the  Russian 
Fleet,  in  the  absence  of  His  Excellency,  Admiral  Hannicoff,  dated  Chatham,  March  9th,  1796. 

“ It  has  been  observed  that  the  fumigation  with  the  nitrous  (nitric)  acid,  introduced  by  M. 
Menzies  on  board  the  ship  “Pamet  Eustaphia”  has  produced  in  a short  time  the  best  effect  in 
stopping  the  progress  of  the  fever  and  other  evils,  which  were  then  evidently  increasing,  for  which 
reason  it  was  not  only  regularly  continued  on  board  of  that  ship,  even  after  M.  Menzies’  departure, 
but  adopted  on  board  of  others,  and  always  found  useful.  It  is,  therefore,  my  duty  to  certify  by 
this,  not  only  the  good  consequences  that  have  been  observed  from  that  useful  contrivance,  but 
even  the  advantage  that  arises  from  its  easy  and  sure  execution  in  comparison  with  other  means 
of  fumigating  the  ships,  which  requires  greater  attention  from  the  fire  that  must  be  made  use  of, 
and  therefore  cannot  be  effectual  in  all  parts  of  the  ship.” 

Those  writers,  as  Dr.  Parkes,  are  in  error  who  refer  the  experiments  of  Mr.  Menzies,  at 
Sheerness,  with  nitrous  acid  fumigations,  according  to  the  method  of  Dr.  Smith,  to  the  year  1785. 
England  was  at  peace  with  other  nations  from  1783  to  1793.  In  the  year  specified  in  the  “Accounts 
of  the  Experiments  made  at  tho  Desire  of  the  Lords  Commissioners  of  the  Admiralty,”  namely,  in 
1795,  England  was  in  alliance  with  Russia,  and  the  fleets  of  the  two  nations  were  acting  in  con- 
junction. 

Fumigations  of  nitrous  acid  were  employed  by  Ramon  da  Luna,'*'  in  yellow  fever,  and  it  is 
asserted  that  no  agent  was  so  effectual  in  arresting  the  spread  of  tho  disease.f 

I have  shown  by  numerous  experiments  upon  living  animals  with  the  binoxide  and  peroxide 
of  nitrogen,  liberated  by  the  action  of  nitric  acid  on  copper  filings,  that  these  gases  are  powerful 
poisons,  exciting  the  muscular,  nervous,  respiratory  and  circulatory  systems,  and,  finally,  pro- 
ducing pulmonary  congestion  and  inflammation,  coma,  convulsions  and  death.  The  blood  in  all  the 
vessels  and  organs  of  the  body  presents  a brownish,  bleached  appearance  after  poisoning  by  this 
gas.  I also  employed  both  nitric  acid  and  chlorine  in  disinfecting  wards  of  Confederate  hospitals 
crowded  with  sufferers  from  typhoid  fever,  measles  and  mumps  during  the  civil  war,  1861-05. 

Chlorine,  regarded  by  many  as  a much  more  powerful  disinfectant,  before  which  muriatio 
acid,  nitric  and  nitrous  acids  were  destined  to  give  way,  was  introduced  as  a fumigating  agent 
by  Fourcroy  in  1791-2  ; and  tho  gas  was  subsequently  introduced  into  England  as  a disinfecting 
agent  by  Dr.  Cruikshank. 


* Ann.  d'Hygiene,  Avril,  1861. 

t“  Medical  and  Surgical  Memoirs,”  Vol.  I,  pp.  298,  327,  512. 


346 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


NOTE  10.  ACID  FUMIGATIONS  ACCORDING  TO  THE  PROCESS  OF  MR.  CRUICKSHANK. 

This  process  is  described  in  a work  by  Dr.  Rollo,  on  the  diabetes  mellitus,  published  at 
London  in  1797.  The  substance  which  is  the  active  agent  in  this  process  is  really  chlorine,  but 
designated  by  Cruickshank  as  the  oxygenated  muriatic  acid  gas. 

Dr.  Rollo  says : “ It  is  observed  that  the  oxygenated  muriatic  acid  gas  was  found  to  destroy 
the  offensive  smell  of  sores,  that  it  destroyed  specific  contagion,  and  could  be  easily  obtained,  and 
very  safely  used.  We  had,  therefore,  given  it  a preference  to  other  things ; and  in  order  that  it 
may  be  more  generally  tried,  we  must  insist  on  Mr.  Cruickshank’s  manner  of  procuring  and  using 
it  in  tho  wards  of  this  hospital. 

“ This  consists  in  intimately  mixing  two  parts  of  common  salt  and  one  of  crystallized  man- 
ganese previously  reduced  to  powder.  Two  ounces  of  this  compound  are  introduced  into  a small 
basin ; about  an  ounce  of  water  is  then  added,  and  afterward  an  ounce  and  a half  of  the  concen- 
t ated  vitriolic  or  sulphuric  acid,  at  different  times,  so  as  to  preserve  a gradual  discharge  of  the 
oxygenated  muriatic  gas.  One  of  these  basins  is  sufficient  for  a ward  or  room  containing  five  or 
six  beds,  and  more  must  be  employed  according  to  the  size  of  the  apartment.” 

As  long  ago  as  1807  fumigations  of  chlorine  were  used  by  Mojon*  to  destroy  the  emanations 
from  the  stools  of  dysentery,  with  the  best  effects  ; and  this  gas  has  also  been  employed  as  a dis- 
infectant in  typhus  exanthemicus.  Many  experiments  made  in  Austria  and  Hungary,  in  1832, 
seem  to  prove  that  chlorine  diffused  in  the  air  has  no  action  on  the  spread  of  cholera.  Mr. 
Ilerapath,  of  Bristol,  asserted,  in  1849,  that  it  was  a complete  preservative,  and  an  opinion  partly 
to  the  same  effect  was  expressed  in  Paris  in  1865  ; but  the  Hungarian  experiments  are  much 
more  conclusive,  inasmuch  as  they  were  positive,  and  not  negative,  results — that  is  to  say,  chlor- 
ine did  not  prevent  the  outbreak  of  cholera.  Charcoal  also,  so  far,  appears  inert,  as  in  the 
Crimean  war  cholera  prevailed  severely  on  board  a ship  loaded  with  charcoal. 

On  the  other  hand,  Ramon  da  Luna  has  asserted  that  nitrous  acid  has  really  a preservative 
effect  against  cholera,  and  that  no  one  was  attacked  in  Madrid  who  used  fumigations  of  nitrous 
acid.  But  negative  evidence  of  this  kind  requires  to  be  on  a very  large  basis  to  prove  such  an 
action.  At  the  same  time,  the  facts  should  certainly  lead  to  a fair  trial  of  nitrous  acid  fumes  in 
all  cholera  epidemics.  In  none  of  the  trials,  however,  were  the  substances  added  to  the  stools; 
they  were  merely  diffused  in  the  air.| 

The  testimony  of  Mojon,  in  1807,  as  to  the  value  of  chlorine  fumigations  in  dysentery  is  posi- 
tive. Thus  he  says  : — 

“The  dysentery  became  contagious  in  the  hospital  at  Gtfnoa;  almost  all  the  sick  of  my  divi- 
sion, nearly  two  hundred,  were  attacked.  And,  as  we  know  that  this  disease,  when  contagious, 
is  communicated  ordinarily  from  one  person  to  another  by  the  abuse,  which  exists  in  all  hospitals, 
of  making  the  same  latrines  serve  for  all  the  sick  of  a ward,  I wished  to  see  if  fumigations  of 
chlorine  had  the  power  of  destroying  these  contagious  exhalations.  I therefore  caused  fumiga- 
tions to  be  used  twice  daily  in  the  latrines,  and  in  a few  days  I was  able  to  destroy  that  terrible 
scourge  which  already  had  made  some  victims.” 

It  appears  that  the  chlorine  was  therefore  in  the  air,  and  not  added  to  the  stools. 

Chlorine,  although  widely  diffused  through  nature  in  combination  with  metals,  and  especially 
with  sodium,  was  not  known  in  the  uncombined  state  until  1774,  when  it  was  discovered  by 
Scheele,  and  its  elementary  nature  was  first  established  by  Davy  in  1S10.  In  order  to  understand 
the  terms  used  by  those  who  first  employed  chlorine  as  a disinfectant,  it  is  important  to  note  the 
following  facts:  Chlorine  was  originally  regarded  as  a compound  body,  namely,  Oxygenized 

viuriatic  acid,  or  oxymuriatic  acid.  Muriatic  acid  was  supposed  to  be  a compound  of  oxygen 
with  the  unknown  radicle  muriaticum,  or  murium,  and  chlorine  or  oxygenized  muriatic  acid,  was 
supposed  to  contain  the  same  radicle  united  with  a larger  quantity  of  oxygen. 

Chlorine  owes  its  disinfecting  properties  to  tho  following  well-established  facts : — 

Chlorine  is  one  of  the  heaviest  substances  that  are  gaseous  at  common  temperatures,  being  354 
times  heavier  than  hydrogen,  and  2i  times  heavier  than  atmospheric  air,  and  hence  the  hold  of 
a Bhip,  or  any  confined  space,  may  be  readily  filled  with  this  gas  by  simple  displacement  of  the 
atmospheric  air  and  foul  gases. 


♦Chevallier.  “Traits  des  Disinfectants.” 

t“  A Manual  of  Practical  Hygiene,  etc.”  By  Edmund  A.  Parkes,  m.d.  Sec.  Ed.  LondoD,  188G.  p.  S5. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  347 


It  has  a pungent,  irritating  smell,  and  is  irrespirable  unless  very  much  diluted.  I have  in  the 
first  volume  of  my  Medical  and  Surgical  Memoirs  (pp.  297,  303,  304,  314),  by  a series  of  experi- 
ments, illustrated  the  action  of  chlorine  upon  living  animals,  and  demonstrated  that,  when 
largely  diluted  with  atmospheric  air,  or  with  water,  this  gas  acts  as  a powerful  cardiac  stimulant, 
increasing  both  the  force  and  frequency  of  tho  heart’s  action ; and  that  when  inhaled  in  large 
quantities,  it  acts  as  a powerful  irritant  upon  the  mucous  surfaces  of  tho  throat  and  lungs, 
inducing  pulmonary  congestion,  pneumonia,  convulsions  and  death.  When  absorbed  it  combines 
with  certain  constituents  of  the  blood,  and  chiefly  with  the  coloring  matter  of  the  colored  corpus- 
cles. After  death  caused  by  the  inhalation  of  chlorine,  the  blood  from  all  parts  of  the  body,  as 
well  as  the  muscles  of  the  heart  and  of  voluntary  motion,  presents  a brown  and  bleached  appear- 
ance. Chlorine  is  in  like  manner  destructive  of  plants. 

If  certain  diseases,  as  the  various  forms  of  malarial  fever  and  yellow  fever,  be  propagated  by 
animalculse  or  fungi,  or  by  living  germinal  matter,  or  by  organic  compounds  having  cm  analogous 
composition  and  acting  in  an  analogous  manner  to  ferments,  chlorine  disinfects,  by  destroying 
life,  and  chemically  altering  the  organic  compounds  subjected  to  its  action. 

It  is  well  established  that  chlorine  possesses  very  active  chemical  properties,  and  gives  origin 
to  many  phenomena  of  combination,  substitution  and  indirect  oxidation.  It  is  moreover  non- 
inflammable,  and  does  not  unite  directly  with  oxygen  under  any  circumstances.  At  ordinary 
temperatures,  chlorine  combines  directly  with  all  the  metals,  with  many  metalloids,  such  as  hydro- 
gen and  phosphorus,  and  many  compound  bodies,  as  sulphurous  anhydride,  olefiant  gas,  ben- 
zine and  carbonic  oxide.  Paper  dipped  in  oil  of  turpentine,  and  plunged  in  a vessel  of  chlorine 
gas,  takes  fire  spontaneously,  yielding  abundance  of  hydrochloric  acid  and  carbon.  Chlorine 
displaces  bromine,  iodine  and  fluorine  from  their  combinations,  by  equivalent  substitution. 
Chlorine  also  displaces  hydrogen  by  equivalent  substitution,  one-half  of  the  chlorine  taking  the 
place  of  an  equivalent  quantity  of  hydrogen,  while  the  other  half  unites  with  the  hydrogen 
eliminated.  Chlorine,  by  combining  with  hydrogen  or  a metal,  acts  indirectly  as  an  oxidizing 
agent.  Chlorine  destroys  the  color  of  most  organic  pigments,  and  this  bleaching  action  is  usually 
accompanied  by  oxidation  and  substitution. 

Chlorine  also  destroys  odors  of  various  kinds,  and  possibly  infectious  miasmata,  and  poisonous 
organic  compounds,  by  abstracting  hydrogen,  with  or  without  substitution,  or  by  indirectly 
oxidizing. 

Chlorine,  therefore,  acts  upon  organic  compounds,  and  alters  their  chemical  and  physical 
properties,  in  four  distinct  modes. 

1.  It  may  enter  into  direct  combination. 

2.  It  may  simply  remove  hydrogen,  as  in  the  conversion  of  alcohol  into  aldehyd. 

3.  It  may  act  as  an  oxidizing  agent,  by  liberating  oxygen  from  water. 

4.  It  may  produce  compounds  by  substitution,  in  which  hydrogen  is  diplaced  atom  for  atom 
by  chlorine,  and  hydrochloric  acid  escapes. 

This  kind  of  substitution  is  of  frequent  occurrence,  and  some  of  the  most  instructive  instances  are 
offered  by  the  action  of  chlorine  upon  ether  and  other  derivatives  of  alcohol.  By  attention  to  a num- 
ber of  precautions,  a succession  of  compounds  is  furnished  in  which,  atom  for  atom,  the  hydrogen 
is  displaced  by  chlorine,  until  at  length  the  last  product  obtained  is  the  solid  chloride  of  carbon. 

The  discovery  that  the  substitution  of  chlorine  for  hydrogen  was  practicable,  at  first  excited 
the  greatest  astonishment  among  chemists,  since,  owing  to  the  powerful  attraction  of  chlorine, 
particularly  when  its  electrical  opposition  to  hydrogen  is  borne  in  mind,  the  possibility  of  such 
an  occurrence  was  never  suspected.  The  displacement  of  oxygen  by  chlorine  was  familiar  to  the 
mind  of  the  chemist,  but  the  displacement  of  hydrogen  by  chlorine  was  a circumstance  in  oppo- 
sition to  the  doctrines  of  chemical  attraction  then  prevalent.  The  discovery  of  this  remarkable 
fact  has  led  to  the  production,  by  substitution,  of  an  immense  number  of  analogous  compounds  in 
other  groups  of  organic  bodies. 

It  is  evident,  from  the  preceding  facts,  that  the  discovery  of  chlorine,  and  its  application  to 
the  destruction  (disinfection)  or  chemical  alteration  of  putrefying  and  fermenting  orgauic  com- 
pounds and  animal  poisons,  were  most  important  advances  in  sanitary  science. 

As  we  have  seen,  the  application  of  tho  so-called  oxygenated  muriatic  gas  (chlorine)  was 
employed  at  the  close  of  the  last  century  an  1 in  the  beginning  of  tho  present,  with  success,  both 
in  France  and  in  England,  in  the  destruction  of  contagion  or  infection. 


S48 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


METHODS  OP  FUMIGATION  PRACTICED  IN  THE  BRITISH  NAVY  DURING  THE  EIGHTEENTH  AND 

NINETEENTH  CENTURIES. 

The  following  method  of  extricating  chlorine  (oxygenated  muriatic  gas),  for  the  fumigation 
of  ships,  was  recommended  to  Dr.  C.  Chisholm*  by  Mr.  Cruickshank,  Chemist  to  the  British 
Board  of  Ordnance  : — 

“Let  four  pounds  of  common  salt  bo  intimately  mixed  with  a pound  and  a half  of  manganese 
reduced  to  a fine  powder.  Introduce  them  into  a leaden  vessel,  with  a cover,  and  add  about  two 
pounds  of  water  through  a hole  in  the  cover.  By  means  of  a glass  funnel  introduce,  by  degrees 
and  at  different  times,  three  and  a half  pounds  of  vitriolic  acid.  In  every  addition  of  the 
vitriolic  acid  the  oxygenated  gas  will  escape,  in  great  abundance,  through  a tube  connected  with 
the  vessel,  and  may  be  directed  to  any  place  and  in  any  quantity  we  please.  By  the  application 
of  a moderate  heat  to  the  vessel  a very  considerable  quantity  of  gas  may  be  obtained  from  the 
same  materials,  after  they  have  ceased  to  give  out  any  in  the  cold.” 

Dr.  Chisholm  affirmed  that : “ This  acid,  in  moderate  quantities,  may  be  employed  to  correct 
putrid  and  offensive  smells  in  any  particular  ward,  without  removing  the  patients,  and  this  it 
effects  more  completely  than  vinegar  or  any  other  means  usually  employed.” 

Dr.  Thomas  Trotter, f Dr.  C.  ChisholmJ  and  Dr.  Samuel  L.  Mitchell^  opposed  the  method  of 
Dr.  Carmichael  Smyth,  for  preventing  or  stopping  contagious  diseases  on  shipboard  by  nitron* 
fumigation  ; but  this  discussion  is  not  worthy  of  further  consideration,  as  the  writings  of  Drs. 
Trotter,  Mitchell  and  Chisholm  on  this  subject  are  singularly  wanting  in  accurate  details  of 
experiments  illustrating  the  exact  value  of  the  so-called  nitrous  fumigations,  although  these 
authors  possessed  superior  advantages  for  a thorough  and  scientific  investigation  of  the  subject. 

Dr.  Trotter  justly  lays  great  stress  upon  the  value  of  free  ventilation  in  ships;  Dr.  Mitchell 
advocated  strenuously  the  use  of  lime  for  the  destruction  of  septic  poison,  and  Dr.  Chisholm,  while 
admitting  the  value  of  free  ventilation,  advocated  the  use  of  vinegar  as  a disinfectant  in  ships 
and  hospitals. 

Dr.  Lind, ||  one  of  the  highest  authorities  of  his  day  in  all  that  relates  to  the  hygiene  of  ships 
and  seamen,  in  speaking  of  certain  contagious  diseases,  says : — 

“ The  clearest  idea  we  can  conceive  of  the  manner  in  which  this  infection  is  communicated  is 
to  suppose  there  is,  in  all  infected  places,  adhering  to  certain  substances  an  envenomed  nidus,  or 
source  of  effluvia  corpuscles,  or  whatsoever  infection  may  be  supposed  to  consist,  and  that,  as  the 
air  is  more  or  less  confined,  becomes  more  or  less  strongly  impregnated  with  them.” 

In  some  parts  of  his  valuable  papers  on  fever  and  infection,  Dr.  Lind  appears  to  be  satisfied  that 
animalculie  had  nothing  to  do  with  the  propagation  of  contagion;  but  in  the  preceding  quotation 
he  modifies  the  old  doctrine  and  expresses  it  in  terms  closely  allied  to  those  used  by  some  modern 
writers.  Dr.  Lind  looked  upon  infected  clothing  as  the  envenomed  nidus,  where  a new  genera- 
tion of  corpuscles  were  multiplied,  which  gave  to  the  noxious  matter  an  increased  virulence,  and 
became  more  certainly  productive  of  the  disease  than  when  it  first  diffused  itself  from  the  body. 

That  this  was  his  meaning  is  abundantly  confirmed  by  his  rules  for  expelling  and  purifying 
contagion.  Every  substance  which  he  prescribes  is  with  the  direct  intention  to  destroy  animal 
life;  hence,  the  heat  of  an  oven,  fumigations  with  sulphur  ( brimstone ),  gunpowder,  tobacco 
smoke,  boiling  vinegar,  etc.,  are  his  main  agents. 

It  was  not  merely  to  purify  clothes,  bedding,  and  other  substances,  that  Dr.  Lind  applied 
fumigations  with  these  substances,  but  the  wards  of  the  sick  in  hospitals  and  the  decks  and  holds 
of  ships  became  also  subject  to  the  process. 

The  population  of  a British  ship  of  war  before  the  application  of  steam  to  navigation  was 
more  dense  than  that  of  the  most  crowded  city  ; and  hence,  from  the  earliest  history  of  the  navy 


*" An  Essay  on  the  Malignant  Pestilential  Fever  introduced  into  the  West  India  Islands  froiu 
Boullam,  on  the  Coast  of  Guinea,  as  it  appeared  in  1793, 1794,  1795  and  1796,  etc.”  By  C.  Chisholm,  m.d. 
■2d  Ed.  London,  1801.  p.  30. 

f“Medicina  Nautica;  an  Essay  on  the  Diseases  of  Seamen.”  3 Vols.  2d  Ed.  London,  1804.  Vol.  I, 
pp.  171-251,  pp.  302-362,  pp.  431-457;  Vol.  II,  pp.  32-78,  pp.  274-436;  Vol.  Ill,  pp.  144-298. 

J"  An  Essay  on  Malignant  Pestilential  Fever,  introduced  into  the  West  India  Islands,  1793,  1"9  , 
1795  and  1796.”  2d  Ed.  London,  1801.  Vol.  II,  pp.  25-36. 

I The  Medical  Repository.  Conducted  by  Samuel  L.  Mitchell,  m.d.,  Edward  Miller,  m.d.  and  Elisha 
Smith.  New  York.  Vols.  i,  ii,  hi  and  iv.  II  Papers  on  Infection. 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  349 


of  this  great  and  conquering  nation  we  find  that  minute  attention  was  paid  to  the  health  of  the 
seamen  ; and  measures  were  adopted  at  an  early  day  for  the  arrest  of  those  contagious  diseases, 
as  typhus  and  yellow  fever,  which  were  prone  to  spread  with  great  rapidity,  and  to  commit  fear- 
ful ravages  in  fleets.  And  it  is  but  strict  justice  to  say  that,  while  the  world  is  indebted  to  Eng- 
land for  the  discovery  of  the  means  of  arresting  smallpox  and  preventing  the  fearful  ravages  of 
scurvy  in  navies  and  armies,  we  are  also  indebted  to  the  same  country  for  the  first  and  most  thor- 
ough system  of  fumigating  and  disinfecting  ships  affected  with  contagious  diseases. 

In  proof  of  this  assertion,  we  select  the  following  account  of  “ The  Means  used  to  eradicate 
a Malignant  Fever  which  raged  on  board  His  Majesty's  ship  ‘Brunswick,’  at  Spithead,  in  the 
spring  of  the  year  1791;  with  some  short  observations  on  the  most  probable  Means  of  preserving 
the  Health  of  a Ship's  Company  : by  Sir  Roger  Curtis ,*  the  captain  of  the  ‘Brunswick.’  ” 

“ The  health  of  the  crews  of  His  Majesty’s  ships  is  a consideration  of  so  important  a nature 
that  whatever  may  contribute  to  its  preservation,  or  to  the  removal  of  contagion  when  it  unhappily 
exists  among  them,  are  circumstances  which  merit  the  serious  attention  of  every  officer.  Those 
who  are  conversant  with  our  maritime  history  must  have  regarded  with  horror  the  dreadful  havoc 
which  disease,  for  a long  continued  series  of  years,  made  among  the  seamen  of  this  country.  They 
will  have  observed  that  disease  carried  off  a hundred  times  more  than  fell  by  the  hands  of  the 
enemy.  During  these  unhappy  periods  it  is  true  that  medical  skill  had  not  reached  the  degree 
of  perfection  it  now  possesses;  but  the  chief  cause  of  the  dreadful  calamities  which  befell  our 
fleets  was  the  want  of  that  order,  cleanliness,  and  internal  economy  which  is  now  more  generally 
observed.  It  is  now  proved  that  a due  attention  to  these  circumstances  operates  most  powerfully, 
in  all  situations,  toward  the  preservation  of  health.  But,  notwithstanding  the  strictest  adherence 
to  the  wisest  precautions,  disease  but  too  often  finds  its  way  among  us.  Fevers  of  the  most  infec- 
tious and  dangerous  kind  frequently  rage  in  our  ships.  They  are  sometimes  generated  there, 
by  a want  of  cleanliness  in  the  ships  and  in  the  people ; but  they  are  more  generally  propagated 
by  the  introduction  of  infected  persons. 

“ When  contagion  has  once  taken  root  in  a ship  the  different  parts  of  it,  as  well  as  the  per- 
sons and  clothes  of  the  crew,  become  highly  infected,  and  it  cannot  be  removed  without  great 
labor  and  perseverance.  Under  circumstances  where  neither  the  stores  nor  the  crew  can  be 
removed  from  the  ship  the  difficulty  of  eradicating  infection  is  greatly  augmented  ; but  even  thus 
situated  it  is  possible  to  be  effected.  It  requires,  however,  great  and  unremitting  pains.  The 
slight  and  ordinary  modes  of  fumigation,  by  correcting  the  air,  are  serviceable  in  the  prevention 
of  sickness ; but  when  contagion  is  established  a more  powerful  application  of  it,  and  other 
means,  must  be  adopted. 

“ The  ‘ Brunswick  ’ was  afflicted  with  a putrid  and  highly  infectious  fever,  when  lying  at  Spit- 
head,  in  the  spring  of  1791,  which  raged  so  violently  that  frequently  ten  or  fifteen  men  would 
fall  down  in  it  in  a day,  and  more  than  one  hundred  and  fifty  were  in  the  hospital  at  Haslar  at 
one  time. 

“ Its  progress  in  the  ship  was,  however,  at  last  arrested,  and  the  means  made  use  of  as  here- 
after related,  that  they  may  be  followed  by  others  under  similar  circumstances,  if  they  are 
deemed  to  be  deserving  of  notice. 

“ As  seamen  have  great  reluctance  in  complaining  when  they  find  themselves  but  slightly 
indisposed,  and  it  being  very  material  that  infected  persons  should,  as  speedily  as  possible,  be 
removed  from  the  body  of  the  ship’s  company,  to  impede  further  communication  of  the  disease 
as  well  as  to  facilitate  the  care  of  those  attacked  by  an  early  application  of  medicine,  great 
attention  was  observed  by  all  the  officers  in  immediately  reporting  every  man  who  appeared  to 
have  the  smallest  indisposition,  whether  it  was  discovered  by  day  or  by  night.  The  whole  space 
under  the  forecastle,  on  the  larboard  side,  including  the  round  house,  was  appropriated  to  the  sick, 
and  the  obtrusion  of  any  other  person  absolutely  prevented.  To  this  place  every  person  was 
removed  the  moment  it  was  discovered  that  the  disease  had  seized  him,  and  the  primary  remedies 
toward  cure  immediately  applied,  from  whence,  as  speedily  as  could  be,  he  was  carried  to  the 
hospital,  care  being  had  that  everything  belonging  to  him  was  sent  with  him. 

“ Moisture  operating  more  powerfully  than  any  other  cause  in  the  production  of  disease,  as 


♦Captain  of  the  Fleet  of  Lord  Howe.  “ Medicina  Nautiea.”  An  Essay  on  the  Diseases  of  Seamen,  by 
Thomas  Trotter,  m.d.,  etc.,  Vol.  I,  pp.  431-139. 


I 


350 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


•well  as  in  the  propagation  of  it,  the  first  care  was  tho  endeavor  to  remove  all  humidity  and  foul- 
ness of  air. 

“The  well  was  bailed  out,  scraped  and  swabbed  till  entirely  dry,  and  then  a large  fire  was  kept 
burning  in  it  for  several  hours  every  day,  so  that  the  smallest  dampness  therein  was  not  suffered 
to  remain.  The  hold  had  the  upper  tier  of  casks  removed  from  it  and  sent  on  shore.  Three 
fires  were  then  kindled  in  it  and  kept  burning  for  many  hours  every  day,  confining  the  smoke  as 
much  as  possible  and  occasionally  shifting  the  fires  from  place  to  place ; and  in  the  fuel  made 
use  of  as  many  empty  tar  barrels  were  consumed  as  could  be  collected  for  the  purpose;  at  other 
times,  wood,  and  occasionally  coal,  intermixed  with  shavings  of  tarred  ropes,  every  precaution 
being  constantly  taken  to  prevent  accident.  When  the  fires  were  extinguished,  the  gratings  of 
the  hold  were  removed  and  the  wind-sail  let  down.  The  orlop  was  constantly  kept  as  clear  as 
possible  of  everything  that  prevented  a free  circulation  of  air,  and  a fire  placed  sometimes  in  one 
part  of  it  and  sometimes  in  another.  The  cockpit,  steward  room  and  bread  room  were  treated  in 
the  same  manner.  The  doors  of  all  the  store  rooms  were  occasionally  thrown  open  and  the 
ventilators  worked  unremittingly  day  and  night. 

“ Three  fires  on  each  side  the  ’tween  decks  were  kept  burning  almost  the  whole  day,  and  these 
were,  from  time  to  time,  shifted  to  every  part  of  it.  The  manger  was  cleared  of  all  manner  of 
lumber  and  a fire  occasionally  placed  therein.  The  deck  was  seldom  washed  and  never  but  when 
the  weather  was  such  that  the  people  could  remain  upon  the  upper  deck  until  it  was  perfectly 
dried  by  the  fires  and  the  natural  current  of  the  air.  Nor  was  any  person  permitted  to  go  below, 
under  any  manner  of  pretence,  until  the  general  permission  for  it  was  given.  When  the  dock 
was  not  washed  it  was  kept  perfectly  clean  by  other  means,  and  slops  about  the  decks,  and  every 
sort  of  dampness,  was  especially  guarded  against.  The  sides,  beams,  carlings,  the  deck  overhead 
and  every  part  of  the  ’tween  decks  were  whitewashed  twice  or  thrice  during  the  course  of  the 
disorder. 

“ Fumigation  in  the  hold  was  thus  conducted : four  half  tubs  with  stands  in  them  were  dis- 
posed therein.  In  each  of  the  tubs  was  placed  an  iron  pot  into  which  was  put  almost  two  pounds 
of  brimstone  tied  up  in  a piece  of  canvas.  The  gratings  were  laid  and  so  closely  covered  with 
tarpaulins,  old  hammocks,  swabs,  etc.,  that  none  of  the  smoke  might  escape.  When  everything 
was  prepared,  a red-hot  loggerhead,  or  iron  lid,  was  put  into  each  of  the  iron  pots,  which  set  fire 
to  the  brimstone;  and  the  men  performing  this  service  immediately  leaving  the  hold,  by  a grat- 
ing of  tho  main  hatchway  being  kept  open  for  the  purpose,  the  hatches  were  entirely  closed. 

“ It  was  the  custom  to  fumigate  the  hold,  orlop  and  ’tween  decks  at  the  same  time,  but  as  we 
could  not  be  furnished  with  a sufficient  quantity  of  brimstone  to  make  use  of  it  in  all  the  dif- 
ferent parts  of  the  ship  at  the  same  period,  it  was  usual,  therefore,  to  use  the  brimstone  in  the 
hold,  orlop  and  between  decks  in  rotation;  and  when  the  brimstone  was  not  applied,  there  were 
substituted  what  are  called  devils,  made  of  powder  wetted  with  vinegar.  In  those  parts  of  the 
’tween  decks  least  accessible  to  air,  and  where,  consequently,  there  is  a greater  degree  of  con- 
tagion, the  flashing  of  powder  from  pistols  is  attended  with  very  good  effect,  for  the  shock  of  the 
explosion  assists  very  powerfully  in  dispersing  the  infectious  matter  attached  to  the  timber  of 
the  ship. 

“ During  the  fumigation,  the  men’s  hammocks  were  all  hung  up  in  their  places,  with  their 
mattresses  and  blankets  spread  over  them,  and  all  their  spare  apparel  was  so  disposed  of  upon 
the  guns,  etc.,  as  to  receive  the  full  effects  of  tho  fumigation  ; and  the  clothes  which  the  men  wore 
upon  deck  during  the  time  of  one  fumigation,  were  changed  upon  the  next  and  placed  below, 
that  all  their  things  might  receive  equal  purification. 

“The  gratings  on  tho  main  deck  were  laid  and  covered  with  such  care  that  no  smoke  could 
escape,  and  tho  pots  were  carefully  barred  in.  The  brimstono  in  tubs,  or  tho  devils,  with  other 
safe  precautions,  were  dispersed  about  the  decks  and  then  lighted,  the  persons  who  did  it  escap- 
ing upon  dock  and  closing  the  hatchway  after  them;  tho  operation  was  completed. 

“The  smallest  crevices  of  tho  ship  wore  pervaded  by  the  smoke  and  effluvia  of  tho  brimstone 
and  affected  every  part  of  her  in  a powerful  and  astonishing  manner. 

“ Three  hours  wore  generally  suffered  to  elapse  before  tho  gratings  were  uncovered  and  tho 
ports  opened,  and  a free  circulation  of  the  air  for  a very  considerable  time  was  afterward  necessary 
before  a person  could  remain  below  without  inconvenience.  The  whole  of  the  hull  of  the  ship 
and  everything  thorein,  animate  and  inanimate,  wore  strongly  impregnated  with  tho  fumes  of 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  351 


brimstone,  and  to  such  a degree  that  it  was  perceptible  when  to  leeward  of  the  ship,  at  a con- 
siderable distance  from  her. 

“ In  damp  weather  these  fumigations  wore  practiced  every  day,  and  never  less  than  three 
times  a week.  The  fires  were  continued  daily. 

‘■  The  sick  berths  were  attended  to  with  the  same  solicitude,  to  impede  and  eradicate  infection, 
as  has  been  described  in  respect  to  other  parts  of  the  ship.  Nor  were  the  persons  and  apparel  of 
the  men  disregarded.  Every  man  in  the  ship  was  washed  from  head  to  foot  with  warm  water  and 
soap,  and  more  than  even  our  usual  pains  were  taken  that  they  should  be  cleanly  in  all  respects. 
If  any  old  and  useless  olothes  were  found,  they  were  thrown  overboard.  Such  serviceable  apparel 
as  was  discovered  the  least  filthy  was  washed  and  fumigated,  and  the  men  were  forbidden  to  wear 
woolen  trowsers.  On  fine  days  the  whole  of  their  bedding  was  hung  upon  lines  between  all  the 
masts  and  in  the  rigging,  and  exposed  thus  to  a free  ventilation  for  many  hours,  and  the  clothes 
of  every  kind  were  treated  in  the  same  manner. 

“The  recovered  men,  returned  from  the  hospital,  were  treated,  upon  their  coming  back  to  the 
ship,  with  great  precaution.  Having  received,  at  the  hospital,  notice  of  their  recovery  and  the 
intention  of  their  return,  a careful  officer  was  sent  thither  to  see  all  their  clothes  and  bedding 
well  aired,  by  being  spread  abroad  for  two  days,  and  well  beaten  and  cleaned,  previous  to  their 
coming  to  the  ship.  Upon  their  arrival  on  board,  every  man  was  washed  in  warm  water  and 
with  soap,  and  an  entire  change  of  clothes  was  then  put  upon  him;  all  the  rest  of  his  apparel 
and  his  bedding  were  immediately  fumigated  with  brimstone,  which  was  performed  by  suspend- 
ing it  over  the  fumes  issuing  from  an  iron  pot,  placed  in  a half  tub,  in  a convenient  place  under 
the  forecastle. 

“ Such  were  the  means  made  use  of  with  punctual  and  unceasing  perseverance.  They  cer- 
tainly were  attended  with  no  little  labor,  but  the  fever  with  which  they  were  afflicted  having  been 
entirely  subdued,  the  gratification  arising  from  the  reflection  that  our  endeavors  were  crowned 
with  success  was  the  most  ample  recompense  for  all  our  trouble.” 

OBSERVATIONS  OF  JOHN  HUNTER*  M.D.,  ON  THE  “PRECAUTIONS  TO  BE  TAKEN  IN  SENDING 
TROOPS  TO  THE  WEST  INDIES;  AND  OF  THE  MEANS  OF  PRESERVING  THEIR  HEALTH 
IN  THAT  CLIMATE,  1781-1788.” 

The  following  observations  were  made,  while  Dr.  John  Hunter  had  the  care  and  superintend- 
ence of  the  Military  Hospitals,  in  the  island  of  Jamaica,  from  the  beginning  of  the  year  1781 
till  the  month  of  May  1783.  The  first  edition  of  his  work  was  published  in  1788,  and  contained 
certain  suggestions  for  the  preservation  of  the  health  of  the  British  troops,  which  were  not  modi- 
fied in  the  succeeding  editions,  and  from  which  we  have  condensed  the  following  analysis. 

From  the  first  discovery  of  the  West  Indies,  all  expeditions  and  immigrations  to  that  part  of 
the  world  have  been  attended  with  great  mortality.  Columbus  and  his  companions  suffered 
severely,  and  succeeding  adventurers  have  not  been  more  fortunate.  The  first  British  Military 
expedition  of  any  consequence  to  the  West  Indies,  was  sent  against  Hispaniola,  by  Oliver  Crom- 
well; but  failing  in  an  attempt  upon  that  Island,  they  attacked  Jamaica,  with  better  success. 
The  far  greater  part  of  the  troops  perished  by  sickness  in  a short  time.  The  unfortunate  expedi- 
tion of  the  English  against  Carthagena  is  memorable,  not  less  from  the  mortality  that  attended  it, 
than  from  its  failure;  and  though  England  in  a subsequent  war,  was  more  fortunate  in  her 
attempts  upon  Martinique,  Guadaloupe,  and  the  Havannah,  yet  it  is  a melancholy  truth  that 
there  were  few  of  the  conquering  troops  alive  six  months  after  their  victories.  Great  losses  were 
sustained  in  the  war  which  closed  in  1783,  particularly  at  St.  Lucia,  Jamaica,  and  on  the  Spanish 
Main.  Four  regiments  were  sent  from  England,  in  1780,  to  Jamaica;  they  arrived  there  on  the 
11th  of  August,  and  before  the  end  of  January  ensuing,  not  quite  six  months,  nearly  one  half  of 
them  were  dead,  and  a considerable  part  of  the  remainder  were  unfit  for  service.  Notwithstanding 
these  repeated  losses,  and  the  West  Indies  having  been  a principal  seat  of  war  between  France 
and  England,  no  steps  adequate  to  the  importance  of  the  object  had  been  taken  to  guard  against 
the  mortality. 

* “Observations  on  the  Diseases  of  the  Army  in  Jamaica,  and  on  the  best  means  of  preserving  the 
health  of  Europeans  in  that  climate;  also  observations  on  the  Hepatitis  of  the  East  Indies.”  By  John 
Hunter,  m.d.f.r.s.,  etc.,  Physician  to  the  Army.  3d  edition,  London  1808.  pp.  10-31.  2d  edition,  1795, 
pp.  10-31. 


352 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  disorders  that  prove  fatal  to  soldiers  and  Europeans  in  general  in  the  West  Indies  are  of 
two  kinds,  namely,  fevers  and  fluxes.  They  are  the  concomitants  of  armies  in  all  parts  of  the 
world,  but  in  tropical  countries  they  rage  with  peculiar  violence.  The  means  recommended  by 
Dr.  John  Hunter,  of  preserving  the  health  and  lives  of  soldiers  in  the  West  Indies  were  briefly 
as  follows. 

1.  The  troops  to  be  sent  should  consist  of  well  disciplined,  and  not  new-raised  men;  for  the 
latter  being  less  orderly,  and  not  accustomed  to  the  life  of  a soldier,  are  more  liable  to  disease, 
from  the  necessary  confinement  on  board  the  transports  on  their  passage,  and  suffer  greatly  more 
from  the  climate  than  men  habituated  to  discipline. 

2.  The  men  should  be  embarked  at  a proper  time  of  the  year,  that  is,  about  tbe  end  of  Sep- 
tember, in  order  that  they  may  arrive  in  the  West  Indies  both  at  the  coolest  and  most  healthy 
season  of  the  year.  They  should  proceed  directly  to  the  place  of  destination,  without  touching 
at  any  of  the  islands,  where  they  seldom  fail  to  contract  much  sickness.  If,  however,  it  be  abso- 
lutely necessary  to  stop  at  one  or  other  of  the  islands,  to  be  supplied  with  laboring  negroes,  or  for 
other  purposes  that  the  service  may  require,  the  troops  should  be  kept  on  board  the  transports; 
and  the  transports  should  be  anchored  in  a healthy  station,  at  a distance  from  and  not  to  the 
leeward  of  marshy  ground. 

3.  When  the  troops  are  embarked,  which  they  should  be  on  board  roomy  transports,  the  utmost 
attention  ought  to  be  paid  by  the  officers  to  keep  the  men  clean,  both  in  their  persons  and  berths. 
This  is  done  by  dividing  them  into  two  or  more  watches ; and  making  them  come  regularly  upon 
deck  every  day  with  their  bedding ; also  by  scraping,  smoking,  and  cleaning  between  decks  daily, 
and  by  washing  their  clothes  once  or  twice  a week. 

4.  When  the  troops  arrive  in  the  West  Indies,  they  should  be  quartered  in  barracks  erected  in 
healthy  situations;  and  when  the  accommodations  on  land,  in  houses,  are  insufficient,  they  should 
remain  on  board  tbe  transports  till  the  buildings  are  erected,  for  the  air  at  sea  is  pure  and 
healthy,  and  productive  of  none  of  the  diseases  of  the  country.  It  has  always  been  found  most 
fatal  to  encamp  troops  in  the  West  Indies,  and  it  should  never  be  done  except  on  actual  service. 

In  regard  to  healthy  situations  for  barracks,  there  are  two  kinds;  namely,  dry,  sandy  peninsu- 
las or  islands  near  the  shore,  and  elevated  situations  in  the  mountains.  Elevated  and  mountain- 
ous situations,  are  more  uniformly  healthy  than  dry  and  sandy  places  on  the  coast;  for  the 
neighborhood  of  marshy  ground,  or  accidental  inundations  may  render  these  last  unhealthy. 

5.  When  the  troops  are  properly  disposed  of  as  to  barracks,  there  should  be  a certain  number 
of  negroes  attached  to  each  regiment,  to  do  whatever  duty  or  hard  work  is  to  be  done  in  the 
heat  of  the  day,  frdm  which  they  do  not  suffer,  though  it  is  fatal  to  Europeans. 

6.  The  soldiers  should  be  supplied  with  provisions  from  the  government. 

7.  The  men  should  be  frequently  out  at  exercise;  and  if  it  be  in  the  morning,  and  not  con- 
tinued too  long,  it  will  contribute  to  their  health.  The  evenings  are  also  cool,  but  'motion,  even 
the  most  moderate,  is  attended  with  profuse  perspiration,  in  which  situation  the  men  exposing 
themselves  to  the  cool  air  of  the  night,  with  wot  shirts  upon  their  backs,  become  liable  to  colds, 
rheumatism,  and  other  complaints.  But  after  the  morning  exercise  the  heat  of  the  day  follows 
and  prevents  any  evils  of  that  kind. 

OBSERVATIONS  OF  SIR  GILBERT  BLANE,  M.D.,  ON  THE  CAUSE  OF  SICKNESS  IN  FLEETS  AND  THE 

MEANS  OF  PREVENTION,  1780-1799. 

In  the  year  1780  Sir  Gilbert  Blane  printed  a treatise  for  the  use  of  the  British  fleet,  contain- 
ing general  rules  for  the  prevention  of  sickness,  and  reproduced  it,  with  some  additions,  in  Ins 
Observations  on  the  Diseases  of  Seamen,  the  third  edition  of  which  was  published  in  London  in 
1799. 

The  work  of  Sir  Gilbert  Blane  was  the  result  of  several  years  of  labor  employed  in  the  Public 
service,  chiefly  under  Admiral  Lord  Rodney,  in  a series  of  naval  operations  which  were  produc- 
tive of  events  more  glorious  than  any  before  recorded  in  the  annals  of  Britain.  His  opportunities 
of  experience  were  sufficiently  extensive  to  entitle  his  observations  to  a permanent  place  in  the 
annals  of  medical  science. 

The  following  outlino  will  be  confined  chiefly  to  an  analysis  of  those  portions  of  the  labors  of 
Sir  Gilbert  Blane  which  relate  to  the  hygiene  and  disinfection  of  ships. 

It  would  be  useless  to  enumerate  the  accounts  furnished  by  history  of  tho  losses  and  disap 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  353 


pointments  to  the  public  service  from  the  prevalence  of  disease  in  fleets.  Sir  Richard  Hawkins, 
who  lived  in  tho  beginning  of  the  last  century,  mentions  that  in  twenty  years  he  had  known  of 
ten  thousand  men  who  had  perished  by  the  scurvy.  Commodore  Ansen,  in  the  course  of  his 
voyage  of  circumnavigation,  lost  more  than  four-fifths  of  his  men,  chiefly  by  that  disease.  History 
supplies  us  with  many  instances  of  naval  expeditions  that  have  been  entirely  frustrated  by  tho 
foice  of  disease  alone;  that  under  Count  Mansfeldt  in  1624;  that  under  the  Duke  of  Buckingham 
the  year  after  ; that  under  Sir  Francis  Wheeler  in  1693 ; that  to  Carthagena  in  1741 ; that  of  the 
French  under  D’Auvillo  in  1746;  that  of  the  same  nation  to  Louisbourg  in  1737.  When  Henry 
V was  about  to  invade  France,  he  had  an  army  of  fifty  thousand  men;  but  owing  to  sickness 
which  arose  in  the  army  in  consequence  of  some  delay  in  the  embarkation,  their  number  was 
reduced  to  ten  thousand  at  the  battle  of  Agincourt.  The  disease  of  which  they  died  was  chiefly 
the  dysentery. 

That  the  health  of  a ship’s  company  depends  in  a greater  measure  upon  the  institution  of 
measures  within  the  power  of  the  officers  than  upon  mere  medical  care  and  treatment,  is  strongly 
evinced  by  the  fact  that  different  ships  in  the  same  situation  of  service  enjoy  very  different 
degrees  of  health  ; and  it  has  been  frequently  observed  in  great  fleets  that  out  of  ships  with  the 
same  complement  of  men,  who  have  been  the  same  length  of  time  at  sea,  and  have  been  victualed 
and  watered  in  the  same  manner,  some  are  extremely  sick  while  others  are  free  from  disease. 

The  diseases  most  prevalent  among  seamen  are  fevers,  fluxes  and  the  scurvy;  while  on  the 
other  hand  they  are  to  a great  extent  exempt  from  such  diseases  as  the  gout,  gastric  complaints, 
hypochondriac  and  nervous  disorders,  to  which  the  indolent  and  luxurious  are  subject. 

Man  being  formed  by  nature  for  active  life,  it  is  necessary  to  his  enjoying  health  that  his 
muscular  powers  should  be  exercised  and  that  his  senses  should  be  habituated  to  a certain  strength 
of  impression.  It  is  to  bo  remarked,  however,  that  exercise  and  temperance  may  be  carried  to 
excess,  and  that  in  these  there  is  a certain  salutary  medium ; for  when  labor  and  abstinence 
amount  to  hardship  they  are  equally  pernicious  as  indulgence  and  indolence.  This  is  strongly 
exemplified  in  seamen ; for,  in  consequence  of  what  they  undergo,  they  are  generally  short-lived, 

I and  have  their  constitutions  worn  out  ten  years  before  the  rest  of  the  laborious  part  of  mankind. 
A seaman  at  the  age  of  forty-five,  if  shown  to  a person  not  accustomed  to  be  among  them,  would 
be  taken  by  his  looks  to  be  fifty-five,  or  even  on  the  borders  of  sixty.  The  most  common  chronic 
complaints  which  a long  course  of  fatigue,  exposure  to  the  weather  and  other  hardships,  tend  to 
bring  on  are  pulmonary  consumption,  rheumatism  and  dropsies.  It  is  also  to  be  considered  that 
these  complaints,  particularly  the  last,  are  further  fomented  by  hard  drinking,  which  is  a common 
vice  among  this  class  of  men,  and  they  are  led  to  indulge  in  it  by  the  rigorous  and  irregular  course 
of  duty  incident  to  their  mode  of  life.  To  these  complaints  should  be  added  those  foul  and 
incurable  ulcers  which  are  so  apt  to  arise  at  sea,  particularly  in  a hot  climate.  The  slightest 
' scratch  or  the  smallest  pimple,  more  especially  on  the  lower  extremities,  is  apt  to  spread  and  to 
1 become  an  incurable  ulcer,  so  as  to  end  in  the  loss  of  a limb.  The  nature  of  the  diet  and  the 
malignant  influence  of  tropical  climates  both  conspire  in  producing  them. 

Though  the  venereal  disease  is  less  frequent  in  the  sea  service  than  in  other  situations, 
i owing  to  the  opportunities  of  infection  being  more  rare,  yet  there  is  reason  to  think  that  it 
; may  have  owed  its  origin  to  a sea  life.  It  is  now  agreed  by  those  who  have  fully  considered 
the  subject,  that  this  diseaso  was  not  found  among  the  natives  of  the  New  World  at  its  dis- 
| covery,  for  no  such  fact  is  mentioned  in  tho  narrative  of  Columbus  or  his  son.  But  it  seems 
that  Europeans,  after  making  longer  voyages  than  they  had  ever  before  been  accustomed  to,  and 
living  long  upon  corrupted  and  unnatural  food,  might  under  such  a peculiar  concurrence  of  cir- 
cumstances, engender  a new  disease  when  they  return  into  port,  more  especially  when  they  come 
to  be  connected  with  the  females  of  a new  race  of  people,  so  different  in  their  constitutions  and 
t mode  of  life.  This  is  corroborated  by  what  happened  in  our  own  times  in  the  islands  of  the  South 
, Sea,  in  which  this  disease  was  not  known  before  they  were  discovered,  but  appeared  upon  tho 
arrival  of  the  Europeans,  though  the  ship’s  crew  were  declared  by  the  surgeons  to  be  free  from  it. 

The  diseases  most  frequent  and  prevalent  at  sea  have  this  advantage,  that  they  are  more  the 
subjects  of  prevention  than  most  others,  because  they  depend  upon  remoto  causes  that  are  assign- 
able, and  which  increase  and  diminish  according  to  certain  circumstances  which  are,  in  a great 
measure,  within  our  power. 

The  prevention  of  diseases  is  an  object  as  much  deserving  our  attention  as  their  cure,  for 
Vol.  IV— 23 


354 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


the  art  of  physic  is  at  best  but  fallible,  and  sickness,  under  the  best  medical  management,  is 
productive  of  great  inconvenience,  and  is  attended  with  more  or  less  mortality.  The  means  of 
prevention  are  also  more  within  our  power  than  those  of  cure;  for  it  is  more  in  human  art  to 
remove  contagion  or  alter  a man’s  food  and  clothing,  to  command  what  exercise  he  is  to  use  and 
what  air  he  is  to  breathe,  than  it  is  to  produce  any  given  change  in  the  internal  operations  of  the 
body.  What  we  know  concerning  prevention  is  also  more  certain  and  satisfactory,  inasmuch  as 
it  is  easier  to  investigate  the  external  causes  that  affect  health,  than  to  develop  the  secret  springs 
of  tho  animal  economy. 

The  prevention  of  disease  has  relation  only  to  external  causes  that  affect  health,  and  are 
considered  by  Sir  Gilbert  Blane  under  the  four  heads  of  1.  Air;  2.  Aliment;  3.  Exercise;  4. 
Clothing.  Sir  Gilbert  Blane  also  devotes  a section  to  the  consideration  of  the  regulation  of  heat 
and  cold,  and  observes  that  the  direct  rays  of  the  sun  not  only  produce  that  sudden  and  fatal 
affection  called  the  Coup  de  Soleil,  but  exposure  to  them  is  one  of  the  principal  causes  of  the 
very  fatal  diseases  of  newly-arrived  Europeans.  There  can  be  no  doubt  but  that  fatigue  and 
intemperance  conspire  to  the  same  effect,  but  these  do  not  produce  the  like  diseases  in  temperate 
or  cold  climates.  It  is  evident  from  this  why  women  are  so  much  less  subject  to  the  fevers  of 
tropical  climates  than  men.  That  this  is  not  merely  owing  to  something  in  the  constitution 
peculiar  to  their  sex,  is  proven  by  another  striking  fact.  The  prisoners  of  war  who  were  not 
under  the  influence  of  disease  at  their  capture,  were  observed  to  remain  exempt  from  the  eoi- 
demic  fevers  of  the  West  Indies.  This  has  been  particularly  conspicuous  in  the  years  1T94  and 
1795,  during  which  the  most  deplorable  ravages  ever  known  were  made  in  the  great  armaments 
sent  to  the  West  Indies,  yet  the  prisoners  of  war  remained  exempt  from  it,  according  to  the 
testimony  of  those  who  had  the  custody  of  them  at  Jamaica  and  Antigua.  There  can  be  no  doubt 
that  the  peculiarity  of  situation  to  which  this  is  principally  imputable  is  shelter  from  the  sun. 

With  reference  to  the  noxious  effects  of  land  air  in  particular  situations,  Sir  Gilbert  Blane 
observes : — 

“The  common  air  of  the  atmosphere  at  sea  is  purer  than  on  shore,  which  gives  to  a sea  life  a 
very  great  advantage  over  a life  on  land.  This  advantage  is  still  greater  in  the  tropical  regions, 
where  the  foul  air,  especially  such  as  proceeds  from  woods  and  marshes,  is  so  fatal,  and  where 
the  heat  is  also  considerably  less  at  sea  than  on  shore.  But  this  superior  purity  of  the  air  at  sea 
is  more  than  counterbalanced  by  the  artificial  means  of  propagating  diseases  on  board  of  a ship. 
All  the  diseases  incident  to  a fleet,  except  the  scurvy,  are  more  apt  to  arise  in  a harbor  than  at 
sea,  and  particularly  the  violent  fevers  peculiar  to  hot  climates.  There  are  generally  woods  and 
marshes  adjacent  to  the  anchoring  places  in  the  West  Indies,  and  the  men  are  exposed  to  the  bad 
air  proceeding  from  thence,  either  in  consequence  of  the  ship’s  riding  to  leeward  of  them  or  of 
people’s  going  on  shore  on  the  duties  of  wooding  and  watering,  or  on  military  service.  Instances 
of  this  without  number  might  be  adduced  from  the  accounts  of  voyages  to  all  the  tropical  coun- 
tries. The  fatal  expeditions  of  the  British  to  tho  Bastimentos  and  to  Carthagena,  in  former  wars, 
are  striking  proofs  of  it;  and  the  same  effects,  though  in  a less  degree,  were  seen  while  the  British 
fleet  was  at  Jamaica,  in  1782.  Sir  Gilbert  Blane  has  known  a hundred  yards  in  a road  make  a 
difference  in  the  health  of  a ship  at  anchor,  by  her  being  under  the  lee  of  marshes  in  one  situation 
and  not  in  the  other.  When  people  at  land  are  so  situated  as  not  to  be  exposed  to  the  air  of  woods 
and  marshes,  but  only  to  the  sea  air,  they  are  equally  healthy  as  at  sea.  There  was  a remarkable 
instance  of  this  on  a small  island,  called  Pigeon  Island,  where  forty  men  were  employed  in  mak- 
ing a battery,  and  they  were  there  from  June  to  December,  which  includes  the  most  unhealthy 
time  of  tho  year,  without  a man  dying,  and  with  very  little  sickness  among  them,  though  they 
worked  hard,  lived  on  salt  provisions  and  had  their  habitations  entirely  destroyed  by  the  hurri- 
cane. During  this  time,  nearly  one-half  of  the  garrison  of  St.  Lucia  died,  though  in  circum- 
stances similar  in  every  respect,  except  the  air  of  the  place,  which  blew  from  woods  and  marshes. 
The  duties  of  wooding  and  watering  are  so  unwholesome  that  negroes,  if  possible,  should  be  hired 
to  perform  them.  In  general,  however,  the  employing  of  seamen  in  filling  water  and  cutting 
wood  is  unavoidable,  but  it  should  be  so  managed  as  not  to  allow  them,  on  any  account,  to  stay  ou 
shore  at  night;  for,  beside  that  the  air  is  then  more  unwholsome,  men,  when  asleep,  are  more 
susceptiblo  of  any  harm,  either  from  tho  cold  or  tho  impurity  of  air,  than  when  awake  and 
employed.  The  danger  of  sleeping  in  the  Campagna  of  Rome,  and  on  the  road  from  thence  to 
Naples,  is  a fact  well  known  in  Europe.” 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  355 


As  the  service  necessarily  requires  that  men  should  be  on  shore  more  or  less,  however  unwhole- 
some the  air  may  be,  Sir  Gilbert  Blane  recommended  the  following  means  to  prevent  its  pernicious 
impressions  on  the  body,  tho  most  important  of  which  was,  without  doubt,  the  use  of  Peruvian 
Bark  as  a prophylactic. 

He  says : “ Certaiu  internal  medicines,  such  as  bitters,  aromatics  and  small  quantities  of  vinous 
liquors,  tend  to  preserve  the  body  from  its  bad  effects.  Of  the  bitters,  Peruvian  bark  is,  perhaps, 
the  best;  and  there  is  a well-attested  instance  of  its  efficacy  in  the  account  given  by  Mr.  Robert- 
son of  a voyage  in  the  1 Rainbow,’  to  the  coast  of  Africa;  and  by  the  same  means  Count  Boneval  and 
his  suite  escaped  sickness  in  the  camps  in  Hungary,  while  half  of  the  army  were  cut  off  by  fevers. 
In  consequence  of  Mr.  Robertson’s  representation  of  the  effects  of  bark  in  curing  and  preventing 
the  fevers  of  that  climate,  the  ships  of  war  fitted  out  for  the  coast  of  Guinea  have  been  supplied 
with  it  gratuitously.  The  fever  produced  by  the  impure  air  of  marshes  may  not  appear  for  many 
days  after  the  noxious  principle,  whatever  it  is,  has  been  imbibed,  men  having  been  sometimes 
seized  with  it  more  than  a week  after  they  have  been  at  sea.  It  naturally  occurs,  therefore,  that 
something  may  be  done  in  the  intermediate  time  to  prevent  the  effects  of  this  bad  air,  and  nothing 
is  more  advisable  than  to  take  some  doses  of  Peruvian  bark,  after  clearing  the  bowels  by  a purga- 
tive. Some  facts  show  that  an  interval  of  ten  days  or  a fortnight  may  elapse  between  the  imbib- 
ing of  the  poison  and  its  taking  effect.  And  in  order  to  guard  against  the  diseases  of  this  climate 
in  general,  it  would  be  more  proper  to  take  some  large  doses  of  bark  once  in  either  of  these 
periods  than  to  make  a constant  practice  of  taking  a little,  as  I have  known  some  people  do,  by 
which  they  may  also  render  their  body,  in  some  measure,  insensible  to  its  good  effects.  The  spices 
of  the  country,  such  as  capsicum  and  ginger,  for  which  nature  has  given  the  inhabitants  of  the 
torrid  zone  an  appetite,  have  also  been  found  powerful  in  fortifying  the  body  against  the  influ- 
ence of  noxious  air.  Either  these  or  the  Peruvian  bark,  or  similar  substances  of  a bitter  and 
aromatic  nature,  given  in  wine,  or  if  there  should  be  none,  in  spirits,  to  men  going  upon  unwhole- 
some duty,  have  been  found  to  have  a powerful  effect  in  preventing  them  from  catching  the  fevers 
of  the  climate.” 

Sir  Gilbert  Blane  recommends  that  in  harbors  the  ship  should  be  made  to  ride  with  a spring 
on  the  cable,  that  the  side  may  be  turned  to  the  wind,  whereby  a free  ventilation  will  be  pro- 
duced, and  the  foul  air  from  the  head,  which  is  the  most  offensive  part,  will  not  be  carried  all 
over  the  decks,  as  it  must  be  when  the  ship  rides  head  to  wind. 

Sir  Gilbert  Blane  referred  the  origin  of  the  jail,  otherwise  called  the  ship  and  hospital,  fever 
to  the  noxious  air  generated  by  men  keeping  the  same  clothes  too  long  in  contact  with  the  body, 
while  they  are,  at  the  same  time,  confined  and  crowded  in  small  and  ill-ventilated  apartments. 
Dr.  Cullen  also  ascribed  the  low  nervous  fever  of  Britain  to  a similar  origin,  being  caused,  as  he 
; thinks,  by  an  infection  of  a milder  kind  arising  in  the  clothes  and  houses  of  the  poor,  who  from 
sloth  or  indifference  neglect  to  change  their  linen  and  air  their  houses.  The  greater  number  of 
fevers,  particularly  those  of  the  low  and  malignant  sort,  may  be  traced  to  the  want  of  personal 
I cleanliness  and  defective  ventilation. 

Sir  Gilbert  Blane  discusses  at  length  various  means  of  preventing  the  introduction  of  infection  in 
ships,  the  production  of  infection,  and  the  means  of  eradicating  infection.  He  recommends  the 
most  rigid  examination  of  all  recruits  and  the  exclusion  of  the  diseased,  and  also  the  most  thor- 
ough cleanliness  of  all  parts  of  the  ship  and  of  the  beds  and  clothing  of  the  men,  and  free  ventila- 
i tion  by  means  of  wind-sails,  ventilators  and  fires  kindled  in  various  portions  of  the  ship. 

When,  from  a neglect  of  the  various  measures  to  prevent  the  introduction  and  production  of 
■ infection,  an  infectious  fever  comes  actually  to  prevail,  and  the  infection,  perhaps,  adheres  obsti- 
nately to  the  ship  in  spite  of  cleanliness,  good  air,  good  diet,  and  all  the  other  means  which,  if 
r employed  in  due  time,  would  have  prevented  it,  Sir  Gilbert  Blane  recommends  the  following 
measures  for  eradicating  the  subtle  poison  : — 

The  first  step  toward  this  is  to  prevent  the  disease  from  spreading,  and  this  is  done  by  sepa- 
rating the  sick  from  the  healthy,  and  cutting  off  all  intercourse  as  much  as  possible.  For  this 
I end,  it  is  necessary  to  appropriate  a particular  berth  to  contagious  complaints,  and  not  only  to 
t\  prevent  the  idle  visits  of  men  in  health,  but  to  discover  and  separate  the  persons  affected  with 
i such  complaints  a3  soon  as  possible,  both  to  prevent  them  from  being  caught  by  others,  and 
i because  recent  complaints  are  most  manageable  and  curable.  Officers  might  be  very  useful  in 
making  an  early  discovery  of  complaints  by  observing  those  who  droop  and  look  ill  in  tho  course 


356 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


of  duty  ; for  seamen  think  it  unmanly  to  complain,  and  have  an  aversion  to  being  put  on  the  sick 
list.  In  order  to  prevent  sickness  from  spreading  it  is  not  sufficient  to  cut  off  all  personal  inter- 
course. The  clothes  of  men  are  as  dangerous  a vehicle  of  infection  as  their  persons ; and  it  should 
bo  a strict  and  invariable  rule,  in  case  of  death  from  fever,  flux,  or  smallpox,  to  throw  overboard 
with  the  body  every  article  of  clothing  and  bedding  belonging  to  it.  Upon  the  same  principle,  in 
case  of  recovery  from  any  contagious  disease,  as  it  would  be  too  great  a waste  to  destroy  the 
clothes  and  beds,  they  should  be  smoked,  and  then  scrubbed  or  washed,  before  the  men  join  their 
messes  and  return  to  duty.  This  precaution  is  the  more  necessary,  as  infection  in  a ship  is 
extremely  apt  to  be  communicated  by  bedding,  from  the  custom  of  stowing  the  hammocks  in  the 
netting,  by  which  they  are  brought  into  contact  with  each  other. 

It  sometimes  happens  that  the  number  of  sick  in  a ship  is  so  great  that  it  is  not  possible  to 
take  proper  and  effectual  measures  on  board  for  stopping  the  progress  of  disease.  But  when  she 
can  be  cleared  of  the  sick  by  sending  them  to  an  hospital,  no  pains  should  be  spared  to  extirpate 
the  remaining  seeds  of  infection. 

For  this  purpose  let  their  clothing  and  bedding  be  sent  along  with  them;  let  their  hammocks, 
utensils,  and  whatever  else  they  leave  behind,  be  smoked,  and  either  scrubbed  or  washed  before 
they  are  used  by  other  men,  or  mixed  with  the  ship’s  stores ; let  the  decks,  sides  and  beams  of 
their  berths  be  well  washed,  scraped,  smoked  and  dried  by  fire ; then  let  them  be  fumigated  with 
brimstone  and  charcoal,  and,  finally,  whitewashed  all  over  with  quicklime.  A mode  of  fumiga- 
tion has  been  brought  into  use  by  Dr.  Carmichael  Smith,  the  peculiar  advantage  of  which,  over 
charcoal  and  sulphur,  is  that  it  can  be  put  in  practice  in  the  midst  of  the  sick.  It  consists  in 
pouring  strong  vitriolic  acid  on  powdered  nitre,  whereby  the  latter  is  decomposed  and  the  acid 
rises  in  the  form  of  fumes. 

But  besides  these  recent  infections,  it  sometimes  happens  that  the  seeds  of  disease  adhere  to 
the  timbers  of  a ship  for  months  and  years  together,  and  can  be  eradicated  only  by  a thorough 
cleansing  and  fumigation ; sweeping,  washing,  scraping,  and  airing,  are  not  sufficient  entirely  to 
remove  the  subtle  infectious  matter;  but  they  will  assist  and  will  prepare  it  to  be  acted  upon  by 
heat  and  the  fumes  of  mineral  acids,  which  are  the  only  means  to  be  depended  upon. 

When  a ship  is  at  sea,  these  precautions  cannot  be  taken  so  completely ; but  if  infection  is 
present,  or  is  suspected,  then  cleansing  and  the  nitrous  fumigation  may  be  practiced. 

It  will  also  be  of  great  service  to  make  the  men  expose  their  clothes  to  the  sun  and  wind,  in 
order  to  prevent  or  carry  off  mustiness  or  slight  infection.  If  a strong  infection  be  suspected, 
and  it  cannot  be  afforded  to  destroy  the  clothes,  the  best  means  of  eradicating  the  poison  at  sea  is 
to  hang  them  for  a length  of  time  over  pots  of  burning  brimstone  in  a large  cask  standing  end- 
ways, with  small  apertures  to  admit  air  enough  for  the  brimstone  to  burn;  or  the  nitrous  fumiga- 
tion may  be  used  for  this  purpose. 

Fire,  when  it  can  be  applied  sufficiently  strong,  is  perhaps  to  be  considered  as  the  principal 
agent  of  purification,  by  its  heat  and  the  ventilation  it  occasions.  Next  to  this  may  bo  reckoned 
the  fumes  of  brimstone  and  those  of  nitrous  acid.  The  smoke  of  certain  narcotic  and  resinous 
bodies  has  also  been  recommended,  such  as  tobacco  and  tar.  The  vapor  of  vinegar,  and  the 
smoke  of  gunpowder  have  also  been  used,  but  have  been  known  to  fail. 

There  is  reason  to  think  that  the  open  air  very  soon  dissipates  and  renders  inert  all  infections 
of  the  volatile  kind,  and,  of  course,  the  warmer  the  air  is  the  more  readily  it  will  have  this  effect. 
It  is  accordingly  observed,  that  infection  is  much  less  apt  to  bo  generated  about  the  persons  of 
men,  and  that  it  adheres  to  them  for  a much  less  space  of  time  in  a hot  climate  than  in  a cold  or- 
temperate  one. 

Sir  Gilbert  Blane  saw  so  many  instances  of  filth  and  crowding  in  ships  and  hospitals  in  the 
West  Indies,  without  contagion  being  produced,  and  which  in  Europe  could  hardly  have  failed  to 
produce  it,  or  to  render  it  more  malignant,  that  ho  was  convinced  that  there  is  something  in 
tropical  climates  unfavorable  to  the  production  and  continuance  of  infectious  fevers.  The  ships 
which  bring  this  fevor  from  Europo  generally  get  rid  of  it  soon  after  arriving  in  a warm  climate; 
and  nothing  but  the  highest  degree  of  neglect  can  continue  or  revive  it. 

The  facts  above  mentioned  suggested  to  Sir  Gilbert  Blane  “ what  is  relatod  of  the  plague  at 
Smyrna  and  other  places,  that  it  disappears  at  the  hottest  part  of  the  year.  The  climate  being 
hotter  at  Cairo  than  Aleppo,  the  plague  ceases  a month  sooner  at  the  formor  than  the  latter.  It 
is  also  curious  and  important  to  remark  that  the  true  pestilence  never  has  been  hoard  of  between 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  357 


the  tropics.  It  is  not  easy  to  assign  tho  cause  of  this  effect  of  heat  upon  infection,  as  everything 
relating  to  this  subject  is  very  obscure.  We  can  conceive  it  to  be  owing  to  the  greater  degree  of 
airiness  which  the  heat  of  tho  climate  makes  necessary,  or  to  the  use  of  fewer  woolen  clothes. 
There  may  be  something  in  the  state  of  the  body,  particularly  in  the  pores  of  the  skin  and  lungs, 
which  disposes  them  less  to  produce  or  absorb  tho  poisonous  effluvia,  or,  when  absorbed,  it  may 
more  readily  be  thrown  out  by  perspiration,  with  the  other  acrimony  of  the  blood ; or  more 
probably,  as  has  been  hinted  above,  the  virulent  matter  is  of  such  a degree  of  volatility  as  to  be 
readily  dissipated  in  a certain  degree  of  heat. 

“ There  is  a fact,  which,  though  seemingly  of  a contrary  tendency,  yet  is  in  reality  in  proof  of 
the  same  opinion.  It  is,  that  these  same  diseases  disappear  in  winter;  and  the  same  is  observed 
at  Moscow  and  other  places.  In  this  case,  the  infectious  matter  is  rendered  inert,  but  not  extinct, 
and  the  return  of  heat  sets  it  afloat  in  the  atmosphere,  so  as  to  expose  it  to  human  respiration. 

“Dr.  Guthrie'*'  informs  us  that  infection  is  entangled  and  fixed  by  tho  cold  of  winter  on  the 
doors  and  walls  of  the  houses  of  the  Russian  peasants,  and  that  upon  the  return  of  tho  warm 
season  it  is  let  loose  by  the  thaw,  and  then  becoming  active  produces  diseases.”  “ Observations  on 
the  Diseases  of  Seamen,”  by  Gilbert  Blane,  m.d.,  etc.  Third  edition,  London  1799,  pp.  183-337. 

Sir  Gilbert  Blane  describes  the  bad  effects  of  foul,  damp  air  in  ships,  gives  minute  directions 
for  the  change  of  air  by  means  of  ventilators,  wind-sails  and  fires  in  the  orlop  and  hold,  and 
recommends  that  minute  attention  be  paid  to  the  choice  of  ballast,  for  that  which  is  called 
shingle,  consisting  all  of  pebbles,  is  far  preferable  to  that  which  is  sandy  and  earthy,  as  it  does 
not  so  readily  soak  and  retain  moisture  and  filth,  and  putrid  matter  may  readily  be  washed  out 
of  it.  Sir  Gilbert  Blane  recommended  the  use  of  spruce  beer,  porter,  ale  and  wine,  instead  of  the 
stronger  alcoholic  distilled  liquors. 

He  says  “ The  abuse  of  spirituous  liquors  is  extremely  pernicious  everywhere,  both  as  an 
interruption  to  duty  and  as  it  is  injurious  to  health.  It  is  particularly  so  in  the  West  Indies,  both 
because  the  rum  is  of  a bad  and  unwholesome  quality  and  because  this  species  of  debauchery  is 
more  hurtful  in  a hot  than  in  a cold  climate,  and  one  of  the  most  common  causes  of  exciting  the 
malignant  fevers  peculiar  to  tropical  countries.  It  is  with  reason  that  the  new  rum  is  accused  of 
being  more  unwholesome  than  what  is  old ; for  when  long  kept  it  not  only  becomes  weaker  and 
more  mellow  by  part  of  the  spirit  exhaling,  but  time  is  allowed  for  the  evaporation  of  a certain 
nauseous,  empyreumatic  principle  which  comes  over  in  the  distillation,  and  which  is  very  offensive 
to  the  stomach.  Another  objection  to  the  rum  supplied  in  the  West  Indies  is  the  admixture  of 
lead,  which  it  acquires  from  the  vessels  employed  in  distilling.-)'  It  was  originally  the  custom  to 
serve  seamen  with  their  allowance  of  spirits  undiluted.  The  method  now  in  use,  of  adding  water 
to  it,  was  first  introduced  by  Admiral  Vernon,  in  the  year  1740,  and  got  the  name  of  grog.  This 
was  a great  improvement,  for  the  quantity  of  half  a pint,  which  is  the  daily  allowance  to  each 
man,  will  intoxicate  most  people  to  a considerable  degree,  if  taken  at  once,  in  a pure  state. 

“ The  most  salutary  kind  of  drink,  next  to  malt  liquor  and  spruce  beer,  is  wine.  The  benefit 
which  the  fleet  derived  from  it  at  different  times,  and  the  advantages  it  has  over  spirits,  have  been 
often  taken  notice  of  in  the  former  part  of  this  work.  It  seems  to  be  owing  to  this  that  the 
French  fleet  sometimes  enjoys  superior  health  to  ours  and  is  less  subject  to  the  scurvy.  We  have 
a remarkable  proof  of  this  in  comparing  the  fleet  under  the  command  of  Admiral  Byron  with  that 
under  Count  d’Estaing,  when  they  both  arrived  from  Europe,  on  the  coast  of  America,  in  the  year 
1778,  some  of  the  British  ships  having  been  unserviceable  from  the  uncommon  prevalence  of 
scurvy,  while  the  French  were  not  affected  with  it.  Wine  is  also  preferable  to  every  other  medi- 
cine in  that  low  fever  with  which  ships  are  so  much  infested,  and  there  is  no  cordial  equal  to  good 
wine  in  recruiting  men  who  are  recovering.” 

In  order  to  preserve  water  pure  on  shipboard,  Sir  Gilbert  Blane  recommended  that  a pint  of 
quick  lime  bo  put  into  each  butt  when  it  is  filled.  He  says  “ It  has  tho  advantage  of  not  being 
injurious  to  health,  but  on  the  contrary  is  rather  friendly  to  the  bowels,  tending  to  prevent  and 
check  fluxes.  In  the  year  1779,  several  ships  of  tho  lino  arrived  in  tho  West  Indies  from  England, 
and  they  were  all  afflicted  with  the  flux  except  the  ‘Sterling  Castle,’  which  was  tho  only  ship  in 
which  quicklime  was  put  into  the  water  for  any  culinary  purpose.  Its  action  in  preventing 


* Philosophical  Transactions , Vol.  69. 

f See  a paper  ou  this  subject  in  the  3d  vol.  of  the  Modical  Transactions,  by  J.  Hunter,  m.d. 


358 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


putrefaction  consists,  in  part  at  least,  in  destroying  vegetable  and  animal  life.  An  addition  of 
putrescent  matter  is  produced  in  water  by  the  generation  of  small  insects,  and  the  glaze  that 
collects  on  the  sides  of  the  cask  and  also  what  collects  on  the  surface  of  the  water,  is  a species  of 
vegetation,  of  the  order  called  by  the  naturalists  Alga .*  Quicklime  is  a poison  to  this  species  of 
vegetable  life,  as  well  as  to  insects;  but  upon  whatever  principle  it  depends,  the  property  of  it  in 
preserving  water  sweet  is  so  well  ascertained  that  it  is  inexcusable  ever  to  neglect  the  use  of  it.” 

RULES  FOR  THE  PREVENTION  OF  YELLOW  FEVER,  PROPOSED  BY  SIR  GILBERT  BLANE  IN  1798. 

On  the  26th  of  November,  1798,  Sir  Gilbert  Blane  addressed  to  Rufus  King,  Esq.,  Minister 
Plenipotentiary  from  the  States  of  America  to  the  Court  of  London,  some  remarks  on  the  nature 
of  yellow  fever  and  the  means  of  preventing  it,  from  which  the  following  observations  are 
extracted : — 

“The  first  question  that  occurs  with  a view  to  preventive  measures  is  whether  this  disease  be 
infectious,  and  under  what  circumstances  it  is  so. 

“In  those  situations  in  which  I observed  it  in  the  West  Indies,  it  was  evidently  so.  There 
was  the  most  incontestable  evidence  of  this,  both  on  board  of  ships  and  in  hospitals,  and  the  doubts 
which  have  been  started  on  this  point  seem  to  have  arisen  from  the  operation  of  infection  being 
blended  with  that  of  other  causes  which  must  concur  with  it  in  order  to  give  it  effect. 

“But  whatever  doubts  there  may  be  on  this  subject  in  the  West  Indies,  there  can  be  none  in 
the  climate  of  North  America.  This  will  be  best  proved  and  illustrated  by  an  example. 

“On  the  16th  of  May,  1795,  the  ‘Thetis’  and  ‘ Hussar  ’ frigates  captured  two  French  armed  ships 
from  Guadaloupe,  on  the  coast  of  America.  One  of  these  had  the  yellow  fever  on  board,  and  out 
of  fourteen  men  sent  from  the  ‘ Hussar’  to  take  care  of  her,  nine  died  of  this  fever  before  she  reached 
Halifax,  on  the  2Sth  of  the  same  month,  and  the  five  others  were  sent  to  the  hospital  sick  of  the 
same  distemper.  Part  of  the  prisoners  were  removed  on  board  the  ‘ Hussar,’  and  although  care  was 
taken  to  select  those  seemingly  in  perfect  health,  the  disease  spread  rapidly  in  that  ship,  so  that 
near  one-third  of  the  whole  crew  was  more  or  less  affected  by  it. 

“ This  fact  carries  a conviction  of  the  reality  of  infection,  as  irresistible  as  volumes  of  argument, 
and  it  further  affords  matter  of  important  and  instructive  information,  by  proving  that  the  infec- 
tion may  be  conveyed  by  the  persons  or  clothes  of  men  in  health. 

“ It  is  a question  of  still  more  consequence,  with  a view  to  preventive  measures,  whether  this 
epidemic  has  arisen  in  the  towns  of  North  America  from  internal  causes,  or  whether  it  was 
imported  from  the  West  Indies. 

“ In  order  to  decide  upon  this,  it  will  be  necessary  to  go  back  into  the  origin  of  the  disease,  in 
so  far  as  it  can  be  ascertained. 

“After  laying  together  and  considering  fully  all  the  facts  relating  to  this  subject,  it  appears  to 
me  that  the  yellow  fever  cannot  be  produced  but  in  a season  in  which  the  heat  of  the  atmosphere 
is  pretty  uniformly,  for  a length  of  time,  above  the  80th  degree  of  Fahrenheit’s  thermometer; 
that  under  the  influence  of  this  heat,  Europeans  newly  arrived,  and  more  especially  in  circum- 
stances of  intemperance,  or  fatigue  in  the  sun,  may  bo  subject  to  it  in  many  instances,  but  that  it 
has  usually  become  general  only  by  the  previous  influence  of  that  infection  which  produces  the 
jail,  hospital  or  ship  fever,  or  from  the  influence  of  putrid  exhalations;  and  that  when  so  pro- 
duced it  continues  itself  by  infection.  It  would  be  too  tedious  to  enumerate  the  multiplied  proofs 
of  this  which  have  occurred  to  me  in  my  connection  with  the  public  service.  With  regard  to  the 
effects  of  ship  infection,  it  is  enough  to  say  that  the  seamen  of  ships  of  war  from  England  having 
infectious  fevers  .on  board  were  observed  to  be  most  subject  to  the  yellow  fever,  when  they  arrived 
in  the  West  Indies,  and  that  the  troops  which  have  been  conveyed  in  ill-aired,  crowded  an  I 
sickly  transports,  are  the  most  liable  to  it  after  disembarking ; this  applies  even  to  that  part  of 
them  who  have  arrived  in  health.  And  with  regard  to  the  effoct  of  putrid  exhalations,  I need 
only  mention  that  at  the  time  of  the  battle  of  the  12th  of  April,  1782,  there  was  not  a sickly  ship 
in  our  fleet,  but  many  of  those  officers  and  men  who  were  sent  to  tako  care  of  the  French  prizes 
were  seized  with  the  yellow  fevor  ; and  it  was  obsorved  that  when,  at  any  time,  the  holds  of  these 
ships,  which  woro  full  of  putrid  matter,  were  stirred,  there  was  an  evident  increase  of  these  fevers 
soon  after. 


* See  an  article  in  Rozier's  Journal  dt  Mtdecine,  for  July,  1781,  by  Dr.  Ingenhousz. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


359 


“It  has  been  alleged  by  some  authors  that  the  yellow  fever  is  produced  by  the  same  marshy 
exhalations  which  produce  the  intermittent  and  remittent  fevers,  and  that  it  is  only  a variety  of 
the  latter;  but  the  remitting  fevers  differ  from  it  in  some  essential  symptoms,  and  the  yellow 
fever  has  been  known  to  arise,  both  in  ships  and  on  shore,  whore  men  were  entirely  out  of  reach 
of  the  vapors  of  marshes. 

“ It  may  naturally  bo  expected  that  this  infection  will  not  take  place  except  in  particular  cir- 
cumstances. There  have  been  physicians  paradoxical  enough  to  maintain  that  the  plague  itself 
is  not  infectious,  and  their  principal  argument  is  that  numbers  are  exposed  to  it  without  being 
affected  by  it.  But  the  same  may  be  said  of  the  smallpox,  and  it  is  the  nature  of  all  infection  to 
require  a certain  concurrence  of  circumstances,  both  external  and  in  the  constitutions  of  those 
exposed  to  it,  in  order  to  its  taking  effect.  One  circumstance  necessary  to  the  operation  of  the 
infection  of  the  plague  is  a certain  range  of  atmospheric  heat.  A temperature  about  80°,  or 
below  60°,  will  soon  put  a stop  to  this  epidemic,  so  that  it  was  never  known  between  the  tropics 
nor  within  the  polar  circles;  and  it  is  only  at  certain  seasons  that  it  appears  in  the  temperate 
zone.  The  atmospheric  heat  necessary  for  the  excitement  of  the  yellow  fever  begins  where  that 
of  the  plague  leaves  off,  for  it  has  never  been  known  to  arise  and  prevail  but  when  the  ther- 
mometer stood  for  some  length  of  time  pretty  uniformly  above  80°  as  has  been  already  stated. 

“ In  applying  these  observations  to  the  question  concerning  the  importation  of  the  infection 
into  Philadelphia  and  the  other  towns  of  America,  I cannot  but  think  that  they  make  greatly  for  the 
affirmative;  for  it  is  agreeable  to  the  analogy  of  all  other  infection  that  it  may  be  introduced  so 
as  to  prove  active  in  portions  so  minute  as  to  escape  detection,  and  at  other  times  may  fail  of 
producing  its  effect,  though  in  the  most  accumulated  state. 

“The  circumstances  under  which  it  appears  in  North  America  are,  indeed,  totally  different 
from  those  in  which  it  appears  in  the  West  Indies.  This  fever  had  not  prevailed  in  Philadel- 
phia from  1762  till  1793;  whereas  it  occurs,  more  or  less,  every  year  in  the  West  Indies,  and  its 
prevalence  is  in  proportion  to  the  number  of  new  comers  from  Europe.  If  this  disease  were  the 
spontaneous  production  of  America,  how  comes  it  that  it  did  not  destroy  the  British  armies  which 
acted  in  the  late  war  in  Pennsylvania,  Virginia  and  Carolina,  as  it  has  done  of  late  in  the  West 
Indies?  It  is  also  against  the  laws  of  probability  that  this  fever  should  have  arisen  by  mere  acci- 
dent in  that  year  in  which  a number  of  French  emigrants  had  arrived  from  the  islands  in  which 
it  prevailed,  and  in  a year  in  which  it  had  prevailed  there  to  such  an  unexampled  degree. 

“Supposing  it  established,  therefore,  as  a truth,  that  this  disease  arose  from  imported  infec- 
tion, we  are  next  to  inquire  what  are  the  precautionary  measures  that  ought  to  be  adopted  to  pre- 
vent its  introduction  or  counteract  its  influence. 

“These  divide  themselves  into  three  heads  : first,  the  prevention  of  the  importation  ; secondly, 
the  prevention  of  its  spreading ; thirdly,  the  removal  of  those  circumstances  which  predispose  to 
its  action. 

“Under  the  first  head  is  included  the  regulations  relating  to  quarantines 

“ The  second  head  is  extremely  important,  and  the  neglect  of  it  has  at  all  times  given  occa- 
sion to  the  extensive  spread  of  pestilential  disorders.  The  principle  of  it  is  comprised  in  these 
few  words:  ‘To  discover  the  first  beginnings  of  disease,  and  to  cut  off  all  intercourse  with  the 
infected.’  It  is  at  this  period  only  that  such  a measure  can  be  effectual,  the  number  of  infected 
being  small 

“ The  third  head  is  one  which  has  not  been  commonly  enumerated  and  treated  of  by  those  who 
have  written  on  this  subject.  It  is  only,  however,  necessary  to  reflect  on  the  present  situation  of 
London  to  become  sensible  of  its  great  importance.  It  is  extremely  doubtful  how  far  this  city 
owes  its  safety  to  quarantines  ; and  there  is  no  proof  of  the  pestilence  having  ever  been  stopped  in 
England  by  the  vigilant  detection  of  its  first  invasion,  and  the  consequent  adoption  of  wise  and 
vigorous  measures  to  prevent  intercourse.  But  the  advantages  of  spacious  and  airy  habitations, 
of  personal  cleanliness,  of  dryness  and  cleanliness  from  forming  drains  and  common  sewers,  are 
undeniable.  The  commerce  in  this  age  so  far  exceeds  whatever  was  known  in  former  ages,  that 
there  is,  most  probably,  at  all  times,  enough  of  infection  in  the  warehouses  of  London  to  kindle 
the  flames  of  pestilence  if  the  fuel  was  applied  and  duly  prepared  and  disposed  for  its  action. 

“I  am  not  sufficiently  acquainted  with  the  towns  of  America  to  say  what  improvements  they 
admit  of  in  the  points  above  mentioned.  It  is  evident,  however,  that  the  causes  of  this  fever  are 


360 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


connected  with  those  circumstances  which  belong  to  a town ; for,  if  I am  rightly  informed,  it  has 
not  spread  into  villages  and  single  houses  in  the  country.  As  the  inhabitants  of  America  possess 
habits  of  cleanliness  in  their  persons  and  habitations,  in  common  with  the  rest  of  the  civilized 
world  in  our  times,  the  amendment  required  is  not  in  these  points.  A circumstance  which  you 
mentioned  to  me  regarding  New  York,  to  wit,  that  the  fever  prevailed  only  in  that  quarter  of  the 
town  which  adjoins  the  East  river,  and  had  not  spread  to  that  which  borders  on  the  North  river, 
seems  to  point  out  the  measures  that  are  likely  to  be  most  advisable  and  practicable  for  ameliorat- 
ing the  air  of  the  towns  in  the  American  States.  Drains  and  common  sewers,  therefore,  of  the 
most  perfect  construction  that  can  be  devised  for  promoting  dryness  and  sweetness,  by  carrying  off 
all  superfluous  moisture,  and  for  conveying  all  manner  of  filth  and  soil  under  ground,  could  not 
fail  to  be  highly  conducive  to  general  health,  and  to  prevent  the  future  visitations  of  epidemic 
fevers.  Whether  the  late  fever  has  been  owing  to  imported  infection,  or  to  the  bad  air  of  the 
place,  this  precaution  is  equally  founded  upon  reason.  I consider  the  drains  and  sewers  of  London 
as  the  most  essential  circumstance  in  promoting  that  decency,  comfort  and  health  enjoyed  so  long 
by  this  great  metropolis,  in  a degree  of  which  I believe  there  is  no  example  in  ancient  or  modern 
times.” 

Sir  Gilbert  Blane  adds,  in  a postscript  to  his  letter  to  Minister  Rufus  King,  that  “Upon 
reviewing  the  preceding  letter,  it  has  occurred  to  me  that  in  enumerating  the  different  heads  of 
preventive  means  I ought  to  have  mentioned  what  is  called  expurgation,  that  is,  the  methods 
taken  for  the  expulsion  and  destruction  of  infection  when  the  disease  is  declining  or  has  ceased. 
Dr.  Russell  is  very  full  on  this  subject;  but  since  he  wrote,  there  is  a method  of  fumigation  intro- 
duced by  Dr.  Carmichael  Smith,  of  which  he  has  published  an  account;  and  as  this  has  acquired 
some  name  from  trials  made  in  the  hospitals  for  prisoners  of  war  and  in  the  navy,  I should  think 
it  would  be  worth  a trial  in  America,  as  one  of  the  means  for  the  expurgation  of  the  infection  of 
yellow  fever.”* 

OBSERVATIONS  OF  SIR  WILLIAM  PYM  ON  THE  MEANS  OF  ARRESTING  THE  SPREAD  OF 

YELLOW  FEVER. 

The  principal  object  which  Sir  William  Pym  had  in  view  in  publishing  his  “Observations 
upon  the  Boullam  Fever,  which  has  of  late  years  prevailed  in  the  West  Indies,  on  the  coast  of 
America,  at  Gibraltar,  Cadiz  and  other  parts  of  Spain,”  was  to  counteract  the  influence  which  the 
opinions  of  Dr.  Bancroft  had  upon  the  minds  of  the  public  as  well  as  of  the  profession,  by  bring- 
ing forward  evidence  to  prove  that  it  is  a different  disease  from  the  bilious  remitting  fever  of  warm 
climates;  that  it  is  not  produced  by,  nor  in  any  way  connected  with,  marsh  miasmata ; that  it  has 
not  been  a constant  resident  in  the  West  Indies;  that  it  is  contagious,  and  capable  of  being 
imported  to  and  propagated  in  any  country  enjoying  a certain  degree  of  heat;  that  it  attacks  the 
human  frame  but  once,  and  attacks  in  a comparatively  mild  form,  natives  of  a warm  climate,  or 
Europeans  whose  constitutions  have  been  assimilated  to  a warm  climate  by  a residence  of  three  or 
four  years;  that  it  differs  from  all  other  diseases,  in  having  its  contagious  powers  increased  by  heat 
and  destroyed  by  cold,  or  even  by  a free  circulation  of  moderately  cool  air. 

The  observations  of  Sir  William  Pym  were  commenced  in  the  West  Indies  in  1794,  and  he  was 
present  also  in  Gibraltar  during  the  terrible  epidemic  of  1804. 

The  first  step  which  Sir  William  Pym  proposed,  in  1794,  for  the  arrest  of  the  fever  prevailing 
on  the  island  of  Martinique,  among  the  troops  under  Sir  Charles  Grey,  was  the  change  of  the 
quarters  of  the  troops  to  airy,  elevated  ground,  at  Point  Negro,  close  to  the  sea  and  almost  a mile 
and  a half  distant  from  the  town.  The  soldiers  experienced  an  almost  instantaneous  change  for 
the  better. 

When  Sir  William  Pym  took  charge  of  the  Medical  Department  of  Gibraltar,  in  1S04,  during 
the  indisposition  of  Dr.  North,  ho  drew  up  a code  of  regulations  and  proposed  that  all  the  men 
who  had  been  in  the  West  Indies,  or  who  had  recovered  from  the  disease,  should  be  employed  in 
hospital  duties,  burying  the  dead,  etc.;  that  a convalescent  camp  should  be  established  for  the 
men  discharged  from  the  hospital,  where  they  should  have  their  linen  and  clothes  washed  before 
being  allowed  to  join  thoir  regiments;  that  men  in  barracks  who  had  not  had  the  disease, 


* “Observations  on  the  Diseases  of  Seamen.”  By  Gilbert  Blane,  m.  d.,  f.  r.  s.,  London  and  Edinburg, 
etc.  Third  Ed.,  Loudon,  1799,  pp.  605-613. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  361 


should  be  moved  to  camp;  that  whenever  a soldier  was  taken  ill  ho  should  be  carried  to  the  hos- 
pital by  men  who  had  passed  the  disease;  his  bedding  and  tent  washed,  and  that  his  comrade  and 
all  other  men  in  the  same  tent  should  be  sent,  for  a certain  time,  into  quarantine. 

Although  these  suggestions  were  only  partially  carried  out,  they  proved  so  far  effectual  as  to 
save  1200  of  the  soldiers  from  an  attack  of  the  disease,  while  of  the  civil  population  of  Gibraltar, 
which  amounted  to  nearly  14,000,  only  twenty-eight  escaped  an  attack  of  yellow  fever,  and  of 
this  number,  twelve  had  been  attacked  with  the  same  fever  at  former  periods,  either  in  the  West 
Indies,  Philadelphia  or  Spain. 

As  far  as  our  information  extends,  to  Sir  William  Pym  is  due  the  credit  of  having  first  brought 
prominently  before  the  medical  profession  that  yellow  fever,  as  a general  rule,  attacks  the  same 
individual  but  once,  and  that  those  who  have  passed  through  the  disease  should  alone  be  employed 
in  nursing  and  attending  the  sick. 

The  value  of  the  suggestions  of  Sir  Gilbert  Blane  and  Sir  William  Pym,  as  to  the  immediate 
separation  of  the  first  cases  of  yellow  fever  and  the  establishment  of  a rigid  quarantine  between 
the  sick  and  the  infected  districts  in  the  cities  in  which  the  disease  appears,  received  remarkable 
and  unquestionable  demonstration  in  the  two  largest  American  cities  in  the  years  1820,  1822  and 
1819.  Yellow  fever  appeared  in  Philadelphia  on  the  24th  of  July,  1820,* * * §  and  caused  eighty- 
three  deaths. 

The  deaths  caused  by  preceding  epidemics  in  Philadelphia  were  as  follows.  1699,f  220 
deaths;  1741,^  250  deaths;  1793, $ 4041  deaths;  1797,  ||  1300  deaths;  1798, 3500  deaths; 
1799,**  1000  deaths;  1802,"('f  307  deaths;  1803,  195  deaths;  1805,  3400  deaths. 

The  following  extract  from  a letter  from  the  late  Professor  Samuel  Jackson,  M.D.,  of  Philadel- 
phia, to  the  author,  is  important  as  illustrating  the  measures  adopted  by  the  Board  of  Health,  for 
the  limitation  and  arrest  of  the  disease. 

Philadelphia,  September  7th,  1867. 

Professor  Joseph  Jones,  m.d.  : 

“ My  Most  Esteemed  Friend  : — I had  given  up  all  hopes  of  being  able  to  again  communicate 
with  you ; but  I have  a respite,  very  probably  a short  one,  and  I seize  the  opportunity  to  write 
you  a few  lines.  I received  your  letter  of  July  while  confined  to  my  bed,  and  cannot  express 
the  pleasure  I received  from  your  letter;  it  was  most  cheering  to  my  spirits,  which  were  begin- 
ning to  fail  me.  But  I must  say  it  has  given  me  considerable  anxiety  respecting  yourself.  You 
are,  I fear,  falling  into  the  error  I committed  myself  at  your  time  of  life,  and  to  which  I attribute 
so  many  years  of  suffering,  and  the  miserable  condition  I am  in,  from  worn  out  centres,  the 
[ generators  of  motor  or  mechanical  force.  You  are  overtaxing  your  forces — vital,  organic  and 
physical.  You  are  treading  in  my  footsteps — be  warned  in  time,  and  avoid  the  wretched,  painful 
: life  I have  endured  for  forty  years. 

“ A few  facts  will  make  the  matter  clear  to  you. 

“In  1820,  I was  President  of  the  Board  of  Health.  In  July,  yellow  fever  broke  out;  most 
of  the  members  were  politicians  and  the  labor  of  combating  the  threatened  epidemic  devolved 
on  me.  By  prompt  and  energetic  means,  and  by  the  assumption  of  powers  we  did  not  possess, 
‘I  the  disease  was  confined  and  suppressed  in  the  different  points  in  which  it  appeared  to  be  gener- 
ated. One  of  these,  at  Walnut  street  wharf,  was  the  centre  of  our  commerce.  The  first  cases 
i)  occurred  on  Saturday  night,  and  Mr.  Barker,  whose  counting  house  was  on  the  wharf,  was  then 
lying  very  ill;  he  died  that  night.  To  have  left  it  open  to  the  public,  would  have  exposed  hun- 
dreds to  the  infective  poison.” 

“No  time  was  to  be  lost.  Early  on  Monday  the  streets  leading  to  Front  and  Walnut  were 
' barricaded,  and  the  inhabitants  in  Water  street  and  Front  street,  from  Chestnut  to  Dock,  were 
I ordered  to  remove.” 

“This  was  a very  arbitrary  proceeding,  but  it  proved  effectual — the  epidemic  was  arrested,  but 
nearly  50  cases  scattered  about  the  city,  were  traced  to  this  locality.  I had  the  credit  of  having 

* S.  Jackson,  American  Medical  Record,  1821,  p.  689. 

t “Yellow  Fever,”  by  R.  La  Roche,  M.D.,  Vol.  1,  p.  46.  Charleston  Medical  Journal  and  Review,  1852, 

p.  58.  1 J.  H.  Griscom.  “Visitations  of  Yellow  Fever,”  p.  3. 

§ Carey,  Account  of  the  Malignant  Fever,  p.  116.  If  Benjamin  Rush. 

11  Benjamin  Rush,  Epidemic,  1797.  **  Yellow  Fever,  R.  La  Roche,  Vol.,  1. 

ft  W.  Hume.  Ch.  M.  J.  and  Rev .,  1860,  p.  24,  et  seq. 


362 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


saved  the  city  from  a general  epidemic.  Toward  the  close  I was  taken  down  with  the  disease, 
and  treated,  after  the  fashion  of  that  day,  with  calomel.” 

“I  was  at  this  time  a member  of  the  City  Council,  and  serving  on  the  Water  Committee, 
superintending  the  erection  of  the  water-works,  and  building  the  dam  of  the  Schuylkill,  at  Fair- 
mount,  a most  arduous  duty.  In  addition  to  these  labors,  I was  one  of  the  attending  physicians 
of  the  Almshouse  and  hospital,  and  lecturing  in  Chapman's  Institute,  on  therapeutics.  At 
the  same  time  I was  harrassed  by  some  heavy  debts  of  a firm  in  which  I had  been  concerned. 
For  about  ten  years,  almost  daily,  my  expenditure  of  vital  force  exceeded  the  normal  power  of 
my  constitution,  and  I was  brought  to  the  verge  of  the  grave.  It  was  then  that  I discovered 
that  thero  was  a limit  to  the  production  of  the  forces,  which,  if  exceeded,  caused  a waste  of  the 
organic  structures,  by  a slow  gradual  dissolution.  I immediately  began  to  economize  my  vitil 
expenditure,  and  limited  myself  to  only  what  was  indispensable.  I retired  from  public  life,  and 
contracted  my  social  circle.” 

Yellow  fever  appeared  in  New  York,  on  the  10th  of  July,  1822,  and  ceased  on  the  5th  of 
November,  and  caused  230  deaths. 

In  some  of  the  preceding  epidemics,  the  following  deaths  had  been  caused  by  yellow  fever; 
1702,  570  deaths;  1743,  217  deaths;  1795,  730  deaths;  1798,  2080  deaths;  1799,  76  deaths;  1803, 
6-700  deaths  ; 1805,  340  deaths. 

When  the  yellow  fever  broke  out  in  New  York  in  1791,  after  forty  years  exemption  from  the 
pestilence,  every  physician  then  practicing,  with  the  exception  of  two  or  three  of  the  oldest  mem- 
bers of  the  profession,  were  utter  strangers  to  the  disease.  Instead  of  studying  the  characters  of 
the  disease  with  patient  attention,  they  began  first  to  search  for  evidence  to  prove  its  domestic 
origin,  and  that  it  was  indigenous  to  the  soil,  and  that  is  was  not  a contagious  disease  and  could 
not  be  imported,  and  that  all  measures  of  precaution,  and  especially  the  system  of  quarantine 
restrictions,  were  a useless  and  degrading  imposition. 

In  the  year  1819,  the  Board  of  Health  of  New  York  discarded  the  temporizing  system  of  the 
boards  of  preceding  years,  and  put  in  practice  an  entirely  new  system.  It  was  resolved,  although 
the  disease  might  be  introduced,  to  endeavor  at  least  to  stop  its  mortality  and  mitigate  its  horrors. 
The  disease  was  looked  upon  as  a contagious  pestilence,  and  the  part  of  the  city  where  it  was 
introduced  was  immediately  and  totally  cleared  of  its  inhabitants,  and  those  who  would  not  re- 
move of  their  own  accord,  were  turned  out  of  their  houses  by  force. 

The  result  was  that  only  about  150  cases  and  about  50  deaths  from  yellow  fever  occurred,  which 
was  infinitely  less  than  the  mortality  of  other  years,  especially  1797  and  1798,  when  the  mass  of 
the  population  remained  at  their  homes,  taught  by  their  physicians  to  believe  that  the  disease  was 
some  ordinary  bilious  fever,  which  would  soon  pass  away;  or  that  the  whole  atmosphere  for  miles 
into  the  interior  was  so  tainted  that  it  would  be  folly  to  run  from  it. 

The  Board  of  Health  of  New  York  was  satisfied,  from  the  experience  of  1819,  that  when  yel- 
low fever  is  once  introduced  there  is  no  safety  but  in  flight,  and  that  all  that  can  be  done  is  to 
disperse  the  inhabitants  and  to  remove  the  sick  with  the  utmost  expedition  into  the  puro  air  of 
the  country,  and  to  erect  an  insuperable  barrier  between  the  infected  and  uninfected  parts  of  the 
city.  Accordingly,  they  forthwith  began  to  depopulate  and  barricade  that  part  of  the  city  where 
the  disease  was  introduced,  stopping  up  all  the  streets  and  lanes  which  ran  into  this  section  of  the 
town.  But  such  were  the  prejudices  of  the  community  against  this  novel  procedure,  first  intro- 
duced in  1819,  and  such  the  fallacious  hope  that  the  disease  would  not  continue  to  spread,  that 
the  Board  were  under  the  necessity  of  adopting  this  measure  with  the  greatest  caution;  by  which-  J 
means  the  disease  kept  the  start  of  the  barricades  that  had  been  interposed,  until  the  general 
panic  which  seized  all  the  lower  part  of  the  city,  about  the  first  of  September,  caused  the  inhabit- 
ants to  abandon  their  homes  en  masse,  and  served  to  put  an  entire  stop  to  the  progress  of  the  dis- 
order, except  among  those  few  who  willfully  exposed  themselves  by  remaining  in  their  houses,  or 
by  going  too  far  down  into  the  most  infected  streets.  '* 


* “An  Account  of  the  Yellow  Fever  as  it  prevailed  in  the  city  of  New  York  in  the  Summer  aud 
Autumn  of  1822,"  by  Peter  S.  Townsend,  m.d.  New  York,  1823,  pp.  217,  236. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


363 


DISINFECTANT  ACTION  OF  SULPHUROUS  ANHYDRIDE  AND  SULPHUROUS  ACID. 

The  efficient  agents  in  the  preceding  thorough  system  of  disinfection  as  practiced  in  the 
British  navy  by  Sir  Roger  Curtis  and  other  officers  during  the  past  century,  were 

Cleanliness, 

Free  Ventilation, 

Heat, 

Lime, 

Sulphurous  Anhydride  (sulphurous  acid). 

The  last  mentioned  agent  (sulphurous  anhydride)  appears  to  have  been  the  true  and  essential 
disinfectant  or  destroyer  of  the  organic  poison  inducing  the  contagious  fever. 

Sulphur,  the  first  disinfectant  employed  by  the  ancients,  and  called  sacred  or  divine  by  the 
Greeks,  has  maintained  its  reputation  from  the  time  of  Ulysses,  who  after  killing  the  Suitors, 
fumigated  the  palace  with  burning  sulphur,  to  the  present  moment,  when  it  is  chiefly  relied  on 
for  the  destruction  of  the  poisons  of  contagious  diseases. 

The  advances  of  modern  chemistry  have  enabled  us  to  comprehend  the  effects  of  burning 
sulphur  upon  the  organic  materials  causing  contagious  diseases. 

The  dioxide  of  sulphur,  sulphurous  oxide,  or  sulphurous  anhydride,  resulting  from  the  com- 
bustion (oxidation)  of  sulphur,  is  at  ordinary  temperatures  a colorless,  irrespirable,  poisonous, 
incombustible  gas.  As  it  is  more  than  twice  as  heavy  as  atmospheric  air,  it  may  be  collected  by 
displacement,  and  when  introduced  into  the  hold  of  a ship,  or  in  any  confined  space,  will  gradu- 
ally accumulate  from  the  bottom  upward,  and  thus  expel  the  atmospheric  air. 

It  is  also  important  to  note  that  sulphurous  anhydride  may  very  readily  be  condensed  into  the 
liquid  state  by  a pressure  of  three  atmospheres,  or  by  a freezing  mixture  of  ice  and  salt.  By  its 
evaporation  it  produces  intense  cold,  sufficient  even  to  freeze  itself,  and  rapidly  to  freeze  water  in 
which  it  is  poured. 

If  sulphurous  acid  gas  be  generated  by  pouring  muriatic  acid  upon  the  sulphite  of  lime,  or 
soda,  in  a form  of  apparatus  similar  to  that  of  Babcock’s  fire  engine  or  extinguisher , we  may  not 
only  thus  in  a very  short  space  of  time  evolve  a large  volume  of  gas,  without  the  danger  of  fire,  as 
in  the  burning  of  sulphur,  but  we  are  also  able  by  such  an  arrangement  to  generate  the  gas  under 
high  pressure,  and  when  it  is  allowed  to  escape  into  the  hold  of  a ship,  or  in  any  confined  space, 
a degree  of  cold  may  be  induced,  which  will  be  an  important  factor  in  the  purification  of  the 
atmosphere. 

This  plan  of  disinfection  (the  liberation  of  sulphurous  acid  in  a special  apparatus  by  the  action 
of  hydrochloric  acid  upon  a sulphite)  now  for  the  first  time  proposed,  is  worthy  of  a careful  trial 
at  the  quarantine  stations. 

The  fumes  of  burning  sulphur,  or  sulphurous  anhydride,  when  brought  in  contact  with  the 
moisture  of  the  atmosphere  or  water  is  converted  into  sulphurous  acid. 

Both  sulphurous  anhydride  and  sulphurous  acid  act  as  powerful  reducing  agents;  sulphurous 
acid  bleaches  by  forming  colorless  compounds  with  certain  coloring  matters,  but  it  does  not,  like 
chlorine,  decompose  the  coloring  matter,  for  the  sulphurous  acid  may  either  be  expelled  by  a 
stronger  acid,  or  it  may  be  neutralized  by  an  alkali,  and  the  color  will  bo  restored. 

Sulphurous  anhydride  is  a powerful  antiseptic,  its  power  of  arresting  fermentation  having 
been  recognized  by  the  Greeks  and  Romans  in  the  manufacture  of  wine,  and  it  consequently  has 
long  been  valued  as  a powerful  disinfecting  agent. 

Meat  which  has  been  exposed  to  the  action  of  sulphurous  anhydride  gas  and  then  sealed  up  in 
metallic  canisters  filled  with  nitrogen,  to  which  nitric  oxide  has  been  added  to  remove  tho  last 
traces  of  oxygcD,  may  be  preserved  fresh  for  years.  La  the  process  proposed  to  Mr.  Gamgco  for 
the  preservation  of  fresh  meat  by  sulphurous  acid,  the  animal  is  killed  with  carbonic  oxide  gas 
and  the  meat  is  kept  in  that  gas  and  sulphurous  acid.  Meats  may  thus  be  kept  fresh  and  of  the 
original  color  for  six  weeks.  Meat,  vegetables  and  fruit  subjected  to  the  fumes  of  burning 
sulphur  and  charcoal  and  then  immersed  in  water  containing  tho  sulphurous  acid  in  solution, 
resist  decomposition  and  retain  their  natural  appearance  and  form  for  months. 

It  is  but  just  to  suppose  that  sulphurous  anhydride  acts  as  a disinfectant  in  a complex  man- 
ner. Thus,  it  arrests  decay  in  organic  matter;  it  deoxidizes,  and  afterward  gives  off  its  oxygen 
and  acts  as  an  oxidizer ; it  also  acts  as  an  acid,  and  dissolves  animal  matter. 

Just  as  sulphurous  anhydride  preserves  moat  from  putrefaction  and  change,  in  a similar  man- 


364 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ner,  without  doubt,  it  acts  upon  animal  poisons,  and  arrests  their  changes,  and  so  alters  their 
composition  as  to  destroy  their  poisonous  action.  In  like  manner  sulphurous  anhydride  and  sul- 
phurous acid  destroy  living  germs,  whether  animal  or  vegetable. 

The  theory  of  the  action  of  sulphurous  acid  held  by  those  who  regard  the  germs  of  contagious 
diseases  as  of  parasitic  and  vegetable  origin,  has  been  well  expressed  by  Dr.  Dewar,  of  Kirkcaldy. 
He  says : — 

“It  may  be  well  to  premise  that  our  adoption  of  such  an  auxiliary  implies  a belief  that  the 
enemy  of  which  we  are  in  pursuit  lurks  about  indefinitely;  that  its  vitality  can  outlive  ordinary 
processes  of  decay,  and  that  it  is  transmitted,  or  at  least  located,  in  the  atmosphere.  This  being 
the  case,  we  may  well  assume  that  the  germs  are  parasitic,  most  of  them  of  vegetable  origin;  'that 
some  retain  their  peculiar  properties  independent  of  temperature  or  climate,  and  that  some  even 
can  (as  in  cholera),  in  a dry  climate,  in  the  form  of  dust,  be  carried  by  the  wind  to  distant  points, 
where,  as  they  absorb  moisture,  they  retain  their  power  of  spreading  devastation.” 

He  treated  his  own  cattle  with  sulphurous  anhydride  gas  four  times  a day,  the  sulphur  for  six 
cattle  being  about  as  large  as  a man’s  thumb,  and  burning  for  twenty  minutes,  the  attendant 
being  shut  in  along  with  the  cattle. 

The  cases  of  cure  by  this  means  in  cattle  plague  are  said  to  have  been  very  numerous. 

Dr.  James  Dewar®  has  also  strongly  recommended  sulphurous  acid  as  a topical  application  to 
wounds  and  sores,  and  has  adduced  very  successful  cases  in  which  it  was  employed.  The  wounded 
surfaces  should  either  be  sponged  with  the  acid  of  full  strength,  or  the  spray  of  the  fluid  acid 
should  be  applied  by  a suitable  vaporizer.  Cases  of  wounds  have  been  recorded  in  which,  after 
dressing  in  this  manner,  there  was  rapid  healing,  with  no  discharge  whatever ; but  the  dressings 
require  frequent  changing,  at  least  every  thirty-six  hours. 

Mr.  Crooksf  says : “ A mixture  of  sugar  and  yeast  was  kept  in  a warm  room  until  it  became 
in  a state  of  active  fermentation.  An  aqueous  solution  of  sulphurous  acid  was  added,  when 
the  fermentation  instantly  ceased;  when  examined  under  the  microscope,  after  treatment  with 
sulphurous  acid,  no  apparent  change  was  observed  in  the  appearance  of  the  cells.” 

In  the  use  of  sulphurous  acid  for  the  disinfection  of  ships,  hospitals  and  rooms  it  should  ever 
be  remembered  that  it  is  poisonous  to  both  vegetable  and  animal  life,  and  that,  even  in  smal 
quantities,  it  acts  as  an  irritant  to  the  lungs,  causing  violent  coughing,  which  becomes  painfu. 
anil  dangerous,  according  to  the  amount  used.  Sulphurous  acid  fumigation  is  not,  therefore, 
applicable  to  wards  of  hospitals,  or  cabins  of  ships,  or  rooms  inhabited  by  human  beings.  All 
living  beings  should  be  removed  from  the  space  to  be  disinfected.  This  may  readily  be  accom- 
plished by  fumigating  wards  and  rooms  and  the  different  portions  of  a ship  in  succession.  The 
fumigation  should  be  followed  by  thorough  cleansing  of  the  furniture,  beds  and  floors,  and  white- 
washing in  order  to  remove,  as  far  as  possible,  those  portions  of  contagious  matter  which  have 
been  disinfected  and  embalmed  by  the  gas  ; and  when  the  poison  is  concentrated  and  virulent, 
the  cleansing  and  whitewashing  should  be  followed  by  a second  fumigation. 

Chlorine  is,  without  doubt,  one  of  the  most  effective  disinfectants  and  germicides,  but  it 
should  not  be  used  simultaneously  with  sulphurous  acid.  By  fumigating  alternately  with  sulphurous 
acid  and  with  chlorine  it  would  appear  almost  impossible  for  any  disease  germs  to  survive  in 
any  given  space  of  air. 

Washing  the  floors  and  walls  with  a solution  of  chlorinated  soda,  or  chlorinated  lime,  has 
proved,  at  the  great  quarantine  station  of  Lisbon,  Portugal,  and  in  many  other  places,  effective. 

As  New  Orleans  is  situated  at  the  mouth  of  one  of  the  largest  rivers,  and  as  it  holds  daily 
communication  with  ports  infected  with  yellow  fever,  all  that  relates  to  the  history  of  disinfec- 
tion as  practiced  by  her  sanitary  officers  is  of  interest  and  value,  and  we  present  the  following 
facts  relative  to  the  use  of  sulphurous  acid  at  this  port : — 

Dr.  Alfred  W.  Perry,  who  was  quarantine  physician  to  the  Mississippi  station  from  April 
11th  to  October  14th,  1874,  invented  and  put  to  practical  use  a mechanical  contrivance  for  the 
disinfection  of  ships’  holds,  by  injecting,  by  the  means  of  a blower,  the  fumes  of  burning  sulphur. 

A similar  apparatus  had  been  used  by  the  sugar  refiners  for  the  bleaching  of  brown  sugar  and 
syrups,  and  also  for  influencing  the  process  of  fermentation,  by  the  injection  into  saccharine 
liquids  of  sulphurous  anhydride. 

* Medical  Times  and  Gazelle,  Sept.  21st,  1869,  p.  318.  t “ On  the  Application  of  Disinfectants." 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  365 


The  essential  part  of  the  disinfecting  process  of  Dr.  Perry  was  the  forcing  the  product  of  the 
combustion  of  burning  sulphur,  namely,  sulphurous  anhydride  gas,  S0»,  into  the  hold  and  various 
compartments  of  a ship.  Previous  to  the  adoption  of  this  method  the  hold  of  a ship,  as  well  as 
the  cargo,  the  cabins  and  forecastle,  were  fumigated  by  burning  sulphur  in  iron  pots.  It  had 
been  well  established  by  the  experience  of  many  sanitarians,  at  various  quarantine  establishments 
and  in  various  hospitals  for  the  treatment  of  infectious  diseases,  that  this  was  an  effective  means 
of  practicing  sulphurous  acid  disinfection.  The  only  point  which  appeared  to  be  in  favor  of  the 
new  method  was  that  it  apparently  required  less  time  for  the  accomplishment  of  the  same  results. 

In  the  New  Orleans  Medical  and  Surgical  Journal  for  January,  1874,  is  an  article  by  Dr. 
Perry,  entitled  “ Quarantine  without  Obstruction  to  Commerce,”  which  had  been  read  before  the 
American  Public  Health  Association,  and  from  which  the  following  is  quoted : — 

“I  think  that  time,  as  an  element  of  quarantine,  is  the  least  to  be  depended  on,  the  most 

oppressive  to  commerce,  the  most  costly  and  at  the  same  time  the  least  effective The 

disease  germs  may  occupy  any  part  of  the  vessel  or  cargo,  and  to  be  effective,  the  disinfectant 
should  reach  every  part  of  the  vessel,  every  crevice  of  the  cargo.  This  can  only  be  done  in  a 
cheap,  quick  and  thorough  manner  by  the  use  of  gaseous  or  volatile  disinfectants,  applied  by  a 
special  apparatus  which  I will  describe.  This  method  will  perfectly  destroy  all  disease  germs  and 
can  be  performed  in  four  to  six  hours,  and  will  detain  infected  vessels  less  than  one  day. 

“ The  apparatus  consists  of  one  or  more  force-blowing  machines,  put  in  motion  by  steam  power, 
which  are  connected  with  a furnace  for  generating  sulphurous  acid  gas,  with  an  apparatus  for 
impregnating  air  with  carbolic  acid  vapor,  and  a furnace  for  producing  heated  air.  The  cost  of 
the  apparatus  would  not  exceed  $3000  or  $4000.  It  could  be  placed  either  on  a wharf,  to  which 
vessels  to  be  disinfected  could  be  towed,  or  it  could  be  placed  on  a small  steamboat.” 

In  the  same  journal  for  January,  1875,  is  a “Special  Report  of  Quarantine  Operations  at  the 
Mississippi  Station,  1874,”  by  Dr.  Perry.  The  following  is  quoted: — 

“Soon  after  being  assigned  to  quarantine  duty,  apparatus  was  prepared  to  carry  out  my  ideas 
in  regard  to  the  disinfection  of  vessels.  This  apparatus  was  brought  into  working  order  June 
i 20th,  1S74.  It  consisted  of  a sheet-iron  cylinder,  three  feet  in  diameter,  with  numerous  adjustable 
air-holes  near  the  base;  into  this  was  put  a charge  of  thirty  to  one  hundred  pounds  of  sulphur, 
which  was  lighted  by  a few  burning  shavings;  an  eight-inch  iron  pipe  connected  the  upper  part  of 
this  sulphur  burner  with  the  entrance  opening  of  a No.  2 Sturtevant  fan  blower;  to  the  outlet  was 
[ connected  a short  upright  iron  (eight-inch)  pipe,  and  to  this  was  fastened  an  eight-inch  rubber  hose, 
i The  fan  of  the  blower  was  put  in  motion  by  three  pulleys  of  increasing  speed,  and  made  2500 
. revolutions  per  minute;  the  main  driving  pulley  was  turned  with  a crank  by  two  men.  The 
j whole  apparatus  was  mounted  on  a small,  stout  flatboat,  which  was  towed  to  the  vessel  lying  at. 
: anchor  near  the  quarantine  station,  the  fire  lighted  and  the  blower  started  until  the  shavings  had 
entirely  burned  out  and  the  sparks  had  ceased;  one  end  of  the  rubber  pipe  was  then  connected 
to  the  lower  outlet  and  the  other  end  was  introduced  into  the  vessel.” 

The  details  of  Dr.  Perry’s  contrivance  and  those  of  the  apparatus  now  in  operation  at  the 
Mississippi  Quarantine  Station,  1887,  are  essentially  the  same,  with  the  exception  of  the  use  of 
steam  for  the  propulsion  of  the  wind  power  or  blower. 

The  apparatus  of  Dr.  Perry  was  used  up  to  the  close  of  1879,  and  during  the  period  extending 
from  its  introduction  in  1874  to  this  latter  period,  cases  of  yellow  fever  were  reported  in  New 
Orleans  in  1874,  1875  and  in  1876;  and  in  1878  occurred  the  great  yellow  fever  epidemic  which 
spread  such  terror  throughout  the  valley. 

It  was  evident  from  these  facts  that  mere  fumigation  with  sulphurous  anhydride,  in  the 
absence  of  other  sanitary  measures  and  proper  detention,  was  not  sufficient  to  protect  New  Orleans 
from  the  introduction  of  yellow  fever. 

Upon  the  reorganization  of  the  Board  of  Health  of  the  State  of  Louisiana  in  1880,  I found  the 
Mississippi  Quarantine  Station  in  need  of  a new  wharf  and  extensive  repairs  of  the  fever  hospital, 
smallpox  hospital,  physicians’  and  boatmen’s  quarters,  and  of  new  boats.  The  apparatus  of  Dr. 
Perry  was  practically  useless;  the. iron  cylinder  burned  out  and  the  flat  in  a rotten  and  leaky 
i condition. 

I caused  to  be  constructed  a disinfecting  apparatus  with  a strong  blowor  for  propelling  the 
' sulphurous  anhydride,  and  the  necessary  iron  furnace  for  burning  the  sulphur,  at  an  actual  cost  of 
$249.09  (two  hundred  and  forty-nine  dollars  and  nine  cents). 


366 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  intention  was  to  place  this  upon  a steam  tug  and  operate  it,  and  move  it  from  ship  to  ship 
by  means  of  steam  (see  Report  of  Joseph  Jones,  m.d.,  President  of  the  Board  of  Health  of  the 
State  of  Louisiana  for  1880,  p.  18). 

Large  expenditures,  over  $12,000,  were  required  for  the  necessary  repairs,  and  in  addition  to 
this  threo  of  the  most  wealthy  and  powerful  shipping  corporations  were  in  open  rebellion  against 
the  quarantine  laws  of  Louisiana. 

During  the  entire  period  of  my  term  of  service  I was  compelled  to  conduct  a suit  in  court 
against  Morgan’s  Steamship  and  Texas  Railroad  Company,  which  was  represented  during  a 
considerable  portion  of  the  time,  extending  from  April,  1880,  to  April,  1884,  by  Mr.  Charles 
Whitney,  President  of  the  New  Orleans  Auxiliary  Sanitary  Association. 

The  only  meeting  of  the  Louisiana  State  Legislature  which  occurred  during  this  period  was 
embraced  by  the  enemies  of  quarantine,  led  by  the  friends  and  agents  of  the  President  of  the 
New  Orleans  Auxiliary  Sanitary  Association,  to  array  the  legislature  against  the  State  Board  of 
Health  and  defeat  the  quarantine  laws  of  Louisiana,  and  to  declare  them  unconstitutional,  null 
and  void. 

Under  such  circumstances,  and  pressed  with  enemies  on  all  sides  and  with  diminished  reve- 
nues, the  Board  of  Health  was  unable  to  command  the  necessary  funds  for  the  employment  of 
steam  tugs  and  crews  for  the  rapid  and  thorough  disinfection  of  vessels  by  the  proper  appa- 
ratus. 

Nevertheless  it  has  been  shown  that  under  all  these  difficulties  the  officers  of  the  Board  in- 
spected and,  whenever  necessary,  fumigated  and  disinfected  ten  thousand  (10,000)  vessels,  manned 
by  over  150,000  seamen,  and  not  only  effectually  excluded  yellow  fever  from  New  Orleans  and 
the  valley  of  the  Mississippi,  but  finally,  after  a severe  battle  of  four  years’  duration,  vindicated 
the  quarantine  laws  of  Louisiana  before  the  Supreme  Court  of  the  State. 

In  1884  the  present  mechanical  service  for  disinfecting  ships  by  sulphurous  acid  was  proposed 
by  the  succeeding  President  of  the  Board  of  Health,  which  has  been  made  efficient  by  a legisla- 
tive appropriation  of  $30,000. 

The  principle  of  Dr.  Perry’s  contrivance  was  precisely  the  same  as  that  of  the  apparatus  used 
at  the  Mississippi  station  in  18S5  and  1886,  but  he  was  under  the  necessity  of  operating  his  fan 
by  hand  power,  for  want  of  the  funds  since  supplied  by  the  General  Assembly  of  the  State. 

The  method  practiced  with  infected  ships,  1880-1884,  consisted  of  the  following  measures  : — 

1.  Discharge  of  cargo. 

2.  Thorough  cleansing  of  the  ship,  including  discharge  of  bilge-water  and  washing  out  with  a 
solution  composed  most  generally  of  fifty  pounds  of  copperas  and  five  gallons  of  carbolic  acid 
(Calvert’s  No.  5),  dissolved  in  fifty  gallons  of  water.  A similar  solution  was  employed  in  the  dis- 
infection of  ballast  and  cleansing  of  woodwork,  decks,  etc. 

3.  Fumigation  with  sulphur.  Iron  pots  were  filled  with  sulphur,  which  were  lowered  into 
the  hold  and  placed  in  all  the  compartments  of  the  ship.  The  pots  rested  in  iron  pans  of  water, 
so  as  to  avoid  all  risks  from  fire.  The  sulphur  was  then  ignited  and  all  openings  closed.  The 
sulphur  was  allowed  to  burn  until  the  oxygen  was  consumed  and  naught  remained  but  sulphur- 
ous anhydride  and  nitrogen.  In  infected  ships  the  fumigation  was  repeated  during  successive 
days,  as  often  as  deemed  necessary. 

The  following  results  are  worthy  of  notice  : — 

(а)  All  vermin  were  destroyed  upon  the  ships  thus  treated. 

(б)  No  accident  from  fire  occurred  during  four  years. 

(c)  No  case  of  yellow  fever  was  traced  in  New  Orleans  to  the  cargo  of  a ship  thus  fumigated. 

4.  Coffee  vessels  from  Rio  de  Janeiro,  Havana  and  Vera  Cruz,  during  the  prevalence  of  yel- 
low fever,  discharged  their  cargoes  into  the  large  brick  Government  warehouse  at  the  Mississippi 
quarantine  station,  and  wero  subjected  to  thorough  fumigation  by  sulphurous  acid  gas.  The  dis- 
charge of  the  cargoes  from  infected  vessels  was  made  by  acclimated  men,  who  had  previously 
had  the  yellow  fever. 

5.  When  deemed  necessary  the  large  coffee  warehouses  in  New  Orleans  were  subjected  to 
sulphuric  acid  fumigation.  These  stringent  measures  appeared  to  have  been  necessitated  by 
the  prevalence  of  yellow  fever  at  Rio  do  Janeiro,  Havana  and  Vera  Cruz,  and  also  to  allay  public 
alarm.  The  valley  was  still  agitated  by  the  remembrance  of  the  terrible  epidemio  of  1878,  which 
had  carried  consternation  and  desolation  far  into  the  interior  of  the  continent. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  367 


The  method  invented  and  put  into  practice  in  1874,  by  Dr.  Perry,  is  more  rapid  in  its  action 
than  the  old  method  ; but  it  is  only  adapted  to  those  ports  and  quarantine  establishments  which 
are  able  to  endure  the  expense  of  the  construction  of  the  apparatus  and  its  operation  by  steam. 

Under  the  old  method  it  is  possible,  at  a small  outlay  and  with  a few  men,  to  fumigate  seve- 
ral ships  or  vessels  at  the  same  time. 

Any  quarantine  station,  however  small,  can  thoroughly  and  effectually  disinfect  vessels,  how- 
ever large  or  small,  by  the  old  method,  which  is  in  like  manner  adapted  to  any  vessel  or  ship, 
large  or  small,  in  any  port  and  under  any  circumstances.  In  the  present  condition  of  commerce, 
therefore,  the  new  method  cannot  wholly  displace  the  old  method  of  sulphurous  acid  fumiga- 
tion. 

GERMICIDE  PROPERTIES  OF  SOo. 

One  pound  of  sulphur  when  burned  produces  11/®  cubic  feet  of  sulphur  dioxide  gas.  The 
aqueous  solution  of  this  gas  contains  sulphurous  acid. 

Baxter’s  experiments  show  that  it  is  the  most  potent  volatile  disinfectant  known,  and  as  it  is 
very  soluble,  and  is  little  affected  by  the  presence  of  albumen,  it  is  also  powerful  in  the  disinfec- 
tion of  liquids.  It  destroys  sulphureted  hydrogen,  thus,  SO2  + 2H3S  = 2HsO  + S3,  and  com- 
bines with  ammonia.  This  disinfectant  forms  sulphites,  and  is  a reducing  or  deoxidizing  agent 
in  the  first  place,  for  it  unites  with  the  oxygen  of  many  compounds  to  form  sulphuric  acid,  but  it 
may  give  up  oxygen,  and  when  mixed  with  much  vegetable  matter  the  sulphur  may  come  off  as 
sulphureted  hydrogen.  Sulphur  dioxide  and  sulphurous  acid  and  chlorine  and  permanganate 
of  potassium  mutually  destroy  each  other,  and  therefore  should  not  be  used  together.  Sulphur 
dioxide  destroys  the  activity  of  dry  vaccine  on  points  very  rapidly,  and,  even  when  much  diluted, 
stops  the  amoeboid  movements  of  living  cells,  kills  vibrios,  and  acts  deleteriously  on  vegetation. 
A virulent  liquid  cannot  be  regarded  as  certainly  and  completely  disinfected  by  sulphur  dioxide 
unless  it  has  been  rendered  permanently  and  strongly  acid.  The  greater  solubility  of  this  agent 
renders  it,  ceteris  paribus,  preferable  to  chlorine  or  carbolic  acid  for  the  disinfection  of  liquid 
media.  (Baxter.) 

According  to  Baxter’s  experiments  a larger  percentage  of  sulphur  dioxide  than  of  carbolic 
acid  is  required  for  the  disinfection  of  the  virus  of  infective  inflammation,  but  a smaller  per- 
centage for  other  contagia.  Sulphur  dioxide  preserves  meat  and  other  substances  when  in  closed 
vessels  for  very  long  periods. 

The  power  of  sulphurous  acid  gas  to  destroy  the  virulence  of  vaccine  virus  has  been  demon- 
strated by  several  experiments.  Ten  minutes’  exposure  in  an  atmosphere  saturated  with  sulphur- 
ous anhydride  vapor  was  found  by  both  Baxter  and  Dougall  to  neutralize  the  virulence  of  vac- 
cine dried  upon  ivory  points.  Experiments  made  by  Dr.  George  M.  Sternberg,  in  1878,  showed 
that  liquid  vaccine  is  rendered  inactive  by  exposure  for  four  hours  to  sulphur  dioxide  in  the  pro- 

1 portion  of  five  volumes  to  one  thousand  of  air.  In  experiments  with  dried  virus  upon  ivory 
points,  made  in  1880  by  the  same  observer,  it  was  found  that  virulence  was  destroyed  by  six 

I hours’  exposure  in  an  atmosphere  containing  one  per  cent,  of  this  gas.  Baxter  and  Vallin  have 
tested  the  disinfecting  power  of  sulphur  dioxide  upon  the  virus  of  glanders.  Baxter  found  that 
four  parts  to  one  thousand  in  solution  destroyed  the  virulence  of  material  obtained  from  nostrils 
rubbed  up  in  water  from  the  lungs  of  an  animal  with  glanders. 

Vallin  experimented  with  virulent  pus  from  an  abscess,  obtained  from  a patient  with  glanders 
in  the  Hospital  of  Val-de-gras.  This  pus  was  passed,  by  inoculation,  into  Guinea-pigs  and  other 
animals,  to  produce  the  characteristic  lesions  of  glanders.  Somo  of  this  pus,  placed  in  a watch- 
glass,  was  exposed  for  twelve  hours  to  sulphur  dioxide  generated  by  burning  two  grammes  of 
sulphur  in  a box  having  a capacity  of  100  litres  (equal  to  14  volumes  of  SO2  to  1000  volumes  of 
air).  Disinfection  was  complete,  as  proved  by  inoculation. 

Dr.  Klein,  in  1884,  has  shown  that  swine  fever  can  be  communicated  to  healthy  pigs,  through  the 
air,  by  placing  them  in  the  same  stable  with  diseased  animals,  but  so  separated  from  them  that  no 
bodily  contact  can  take  place  between  the  diseased  and  healthy;  and  that  this  could  certainly  be 
prevented  by  the  presence  of  chlorine  in  the  air  of  the  stable.  Dr.  Klein  made  similar  experi- 
ments with  sulphurous  acid  gas.  It  was  found  that  when  an  animal  seriously  affected  with  swine 
fever  wa3  used  as  a disease  germ,  healthy  animals  introduced  into  the  same  stable  with  it  con- 
tracted the  disease  and  died  of  it,  notwithstanding  that  the  air  of  the  stable  was  impregnated 
with  sulphurous  acid.  But  when  the  same  experiment  was  repeated  with  an  animal  affected  in 


368 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


a mild  form  and  free  from  the  severe  pulmonary  symptoms  which  in  the  other  case  accompanied 
it,  no  infection  took  place. 

It  must  therefore  he  determined  by  further  experiments  how  far  sulphurous  dioxide  is  cap- 
able of  preventing  the  spread  of  contagion  among  living  animals.  (Fourteenth  Annual  Report  of 
the  local  Government  Board,  1884-1885,  pp.  183-187,  London,  1885.) 

HEAT  AS  A DISINFECTING  AGENT. 

It  has  long  been  known  that  heat  acts  as  a powerful  disinfectant  by  its  power  of  destroying 
animal  and  vegetable  life,  coagulating  albuminoid  substances,  and  by  its  desiccating  effects. 

The  absorption  of  noxious  effluvia  by  clothes  or  soft  and  porous  articles  of  merchandise  has 
long  been  recognized  as  a fact  by  men  who  have  directed  special  attention  to  this  subject. 
Many  of  the  liquid  disinfectants  which  have  at  various  times  been  proposed  are  not  applicable  to 
articles  of  clothing;  and  the  common  practice  of  baking  clothes  in  ovens  is  liable  to  lead  to  their 
destruction,  owing  to  the  impossibility  of  regulating  the  temperature  to  which  it  is  necessary  to 
expose  them. 

The  plan  of  Messrs.  Davison  and  Symington  combines  economy  with  certainty  of  disinfection, 
and  consists  in  exposing  the  articles  of  clothing,  in  a large  chamber,  to  rapid  currents  of  air, 
heated  to  a temperature  insufficient  to  injure  them,  varying  from  200°  to  250°  F.  In  the  case  of 
infected  clothing,  it  is  obvious  that  while  a high  temperature  tends  to  destroy  the  animal  poisons, 
a rapid  current  of  air,  constantly  passing  through  the  chamber,  tends  to  carry  them  off.  The 
temperature  of  the  current  of  air  can  be  so  regulated  that  common  albumen  is  speedily  dried  into 
a yellow,  transparent  solid,  without  coagulation,  or,  if  necessary,  the  heat  may  be  increased  from 
400°  to  500°  according  to  the  nature  of  the  articles  which  are  exposed. 

Dr.  Copland  directed  the  attention  of  the  medical  profession  and  sanitary  authorities  to  this 
process,  and  observes  that:  “The  great  advantage  of  this  method  is  its  easy  applicability  to  all 
kinds  and  to  any  number  of  objects  and  articles  without  injury  to  their  textures  or  fabrics.” 
Dr.  A.  N.  Bell,  Vice-President  of  this  Section,  applied  steam  to  the  disinfection  of  vessels  of  war 
in  this  country  in  1847-1848. 

Dr.  Andrew  Ure,*  writing  in  1854,  says:  “ From  an  inspection  of  one  of  these  chambers  when 
the  temperature  of  the  current  of  air  was  116°  F.,  we  can  state  that  the  process  of  Messrs. 
Davison  and  Symington  for  the  drying  and  disinfecting  of  the  clothing  of  cholera  and  fever 
patients  will  be  far  more  efficacious  than  the  common  plan  of  washing  and  baking.  In  our 
opinion,  an  apparatus  of  this  kind,  fitted  up  in  large  hospitals,  infirmaries,  prisons  and  work- 
houses,  as  well  as  all  quarantine  stations,  would  be  admirably  adapted  to  prevent  the  diffusion  of 
contagious  diseases.” 

This  method  might  be  rendered  still  more  efficacious  by  combining  with  the  hot  air  or  steam, 
the  vapor  of  carbolic  acid  or  the  fumes  of  burning  sulphur. 

It  would  manifestly  be  very  difficult,  if  not  impossible,  to  apply  heat  and  hot  air,  or  even 
steam,  and  the  so-called  superheated  steam  (used  by  the  late  Captain  Fry,  of  New  Orleans,  for 
the  seasoning  and  preservation  of  wood),  to  the  disinfection  of  the  holds  and  cabins  of  ships,  or 
the  large  wards  of  hospitals;  and  for  such  purposes  the  sulphurous  acid  fumigation  is  far  more 
rapid  and  efficient. 

The  hot  air  and  steam  process  is  evidently  applicable  chiefly  to  infected  clothing  and  woolen 
and  cotton  goods  and  bedding.  This  process  has  been  used  with  marked  benefit  in  the  disinfec- 
tion of  the  clothing  of  yellow  fever  and  cholera  patients  at  the  quarantine  station  and  large 
hospitals  of  New  York  and  other  cities. 

As  it  is  well  established  that  the  cause  of  yellow  fever  is  arrested  by  cold,  it  has  been  proposed 
to  subject  the  interior  of  ships  and  infected  houses  to  the  action  of  such  an  amount  of  cold  ns  will 
condense  and  freeze  all  moisturo  in  the  air.  Such  a result  would,  without  doubt,  be  practicable 
by  means  of  apparatus  similar  to  the  ammonia  ice-freezing  machine ; but  aside  from  the  difficul- 
ties and  expense  attending  the  artificial  condensation  and  congealing  of  the  moisture  nnd  organic 
matters  in  the  holds  and  cabins  of  ships,  it  is  possible  that  the  poison  inducing  certain  forms  of 
fever,  and  especially  yellow  fever,  may  again  bo  excited  to  renewed  activity  after  the  melting  of 
the  ice.  If  yellow  fever  bo  due  to  a special  plant  or  animalcule,  or  to  a specific  form  of  organic 


* “ A Dictionary  of  Arts,  Manufactures  and  Mines.”  American  Edition,  Vol.  I,  p.  583. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


3G9 


matter,  it  is  possible  that  the  active  properties  may  survive  the  action  of  cold,  as  it  is  well  known 
that  many  of  the  simple  organisms  of  the  vegetable  and  animal  kingdoms  possess  the  power  of 
resisting  great  extremes  of  heat  and  cold,  tho  action  of  these  agents  being  only  temporary,  or 
during  their  immediate  continuance.  It  would  appear  that  in  the  disinfection  of  shijis  such  pro- 
cesses do  not  reach  the  true  source  of  the  difficulty,  and  are  inferior,  and  at  the  same  timo  are 
moro  expensive  and  difficult  than  such  processes  as  the  sulphurous  acid  fumigation,  which  com- 
bines at  once  simplicity,  economy,  efficiency,  and  permanence  of  effects. 

The  experiments  of  Dr.  Henry  Baxter,  IV.  Roberts  and  others  have  shown  the  effects  of  heat 
on  vaccine,  malignant  pustule,  septic  microzymes,  scarlet  fever,  plague,  etc.  High  temperature 
and  length  of  exposure  are,  to  a certain  extent,  mutually  compensatory,  but  it  appears  that  a 
temperature  below  110°  F.  (60°  C.)  will  not  disinfect  vaccine  unless  with  long  exposure. 

Tyndall  points  out  that  some  germs  seem  to  be  in  a dormant  condition,  in  which  they  resist 
the  action  of  heat  unless  applied  very  long  or  intermittently,  so  as  to  start  their  vitality  into 
growth,  when  they  are  easily  killed.  Experimental  facts  show  that  excessive  temperatures  are 
as  unnecessary  as  dangerous  in  practical  disinfection.  It  is  extremely  improbable  that  any  con- 
tagion can  withstand  a temperature  of  220°  F.  (104.5°  C.),  maintained  during  two  hours.  When 
contagion  is  shielded  by  thick  material  into  which  heat  penetrates  slowly,  the  time  necessary  to 
reach  the  disinfecting  temperature  may  be  long,  and  hence  tho  necessity  of  spreading  clothing 
and  opening  out  bedding  in  special  hot-air  chambers  where  the  heat  ought  not  to  be  less  than 
220°  F.  (104.5°  C.)  nor  moro  than  250°  F.  (121.1°  C.).  Hot-air  chambers  are  usually  built  of 
brick  and  are  furnished  with  wooden  supports  for  clothing,  which  should  not  come  in  contact 
with  metallic  or  brick  work.  Metal,  being  a much  better  conductor  of  heat  than  wood,  is  liable  to 
become  so  hot  as  to  lire  the  contents  of  the  drying  chamber.  This  accident  has  twice  occurred 
! (if  the  statements  of  the  public  and  medical  press  are  to  be  credited)  at  the  quarantine  station 
on  the  Mississippi  river,  under  the  charge  of  the  Board  of  Health  of  the  State  of  Louisiana, 
during  the  past  eighteen  months.  The  fire  on  both  occasions  is  said  to  have  originated  in  the 
drying  room  for  the  disinfection  of  infected  clothing  and  goods  by  heat.  Upon  the  first  occasion 
the  flames  communicated  with  and  destroyed  the  quarantine  wharf.  It  has  been  estimated  that 
the  loss  occasioned  by  these  fires  to  the  ships,  passengers  and  property  of  the  State  exceeded 
ten  thousand  dollars. 

The  proposition  to  substitute  metallic  screens  for  wooden  partitions  for  the  clothing  and  goods, 
upon  the  ground  that  under  such  circumstances  the  wire  gauze  would  act  in  a manner  similar 
to  that  employed  by  Sir  Humphrey  Davy  for  the  prevention  of  explosions  in  mines,  is  unscien- 
tific and  unphilosophical.  Such  an  arrangement,  unless  the  heat  was  carefully  regulated,  would 
tend  to  destroy,  rather  than  preserve,  the  clothing  and  goods  subjected  to  heat. 

Heat,  however,  is  perhaps  the  best  agent  that  we  possess  for  disinfecting  infected  clothing  and 
bedding,  provided  they  bo  properly  opened  and  spread  out. 

During  my  term  of  service  as  President  of  the  Board  of  Health  of  the  State  of  Louisiana, 
1880-1884,  yellow  fever  prevailed  in  the  epidemic  form  at  Rio  de  Janeiro,  Havana  and  Vera 
I Cruz,  and  at  Brownsville,  Texas,  and  Pensacola,  Florida.  Many  vessels  which  had  had  yellow 
fever  on  board,  and  upon  which  deaths  from  the  disease  had  occurred  on  the  voyage,  arrived  at 
the  Mississippi  quarantine  station,  then  under  the  charge  of  Dr.  James  F.  Finney,  assisted  by 
Dr.  C.  P.  Wilkinson.  During  this  entire  period  the  process  relied  on  chiefly  for  the  disinfection 
of  the  linen  and  clothing  of  the  patients  treated  in  the  yellow  fever  hospital  and  smallpox  hos- 
ipitalatthe  Mississippi  quarantine  station  was  tho  boiling  and  thorough  washing  required  to 
j cleanse  and  dress  the  clothing;  and  yet  no  case  of  yellow  fever  was  traced  to  this  method. 

Dr.  James  B.  Russell,  medical  officer  of  health  for  Glasgow,  has  recorded  similar  experience 
"as  to  the  efficacy  of  boiling  and  washing  infected  clothing.  Dr.  Russell  states  that  at  the  infec- 
tious diseases  hospital  of  that  city  no  further  disinfection  of  the  linen  and  clothing  of  tho 
° patients  is  carried  out  than  is  afforded  by  tho  boiling  and  washing,  etc.,  required,  in  tho  judgment 
‘f  of  the  washerwoman,  to  cleanse  and  dress  the  clothing;  and  yet  a continuous  careful  scrutiny  has 
failed  to  discern  a single  case  of  disease  propagated  by  such  clothing. 

Dr.  James  B.  Russell,  m.d.c.m. — suggests  that  probably  soda  is  used  in  the  boiling,  in  some 
'cases  at  least,  and  that  the  extreme  softness  of  Glasgow  water  doubtless  helps,  by  its  osmotic  and 
dissolving  power,  to  cleanse  the  clothing. 


Vol.  IV— 24 


370 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  considering  the  applicability  of  heat  as  a means  of  disinfection,  some  distinct  questions 
present  themselves  for  solution,  as — 

1.  The  degree  of  heat  and  the  duration  of  exposure  which  are  necessary  under  different  con- 
ditions, as  of  moisture  and  dryness,  in  order  to  destroy  with  certainty  the  activity  of  the  con- 
tagia of  infectious  diseases. 

2.  How  shall  the  required  degree  of  heat  be  made  to  penetrate  through  bulky  and  badly  con- 
ducting articles,  namely,  clothing  and  bedding,  for  the  disinfection  of  which  heat  is  especially 
employed  ? 

3.  The  degree  of  heat  to  which  clothing,  bedding,  etc.,  can  be  submitted  without  injury,  for, 
if  they  are  injured  by  heat,  disinfection  presents  but  little  advantages  over  destruction,  as  has 
been  recently  demonstrated  at  the  Mississippi  quarantine  station. 

I.  THE  DEGREE  OP  HEAT  HELD  TO  BE  NECESSARY  FOR  THE  DESTRUCTION  OF  THE  CONTAGIA  OF 

INFECTIOUS  DISEASES. 

The  earliest  experiments  on  disinfection  by  heat,  as  distinguished  on  the  one  hand  from 
destruction  by  fire,  and  on  the  other  from  mere  washing  in  boiling  water,  appear  to  be  those 
made  by  Dr.  Henry,  f.  r.s.,  of  Manchester,  and  published  in  the  Philosophical  Magazine  for 
1831. 

These  experiments  were  made  with  a copper  vessel  surrounded  by  a steam  jacket,  the  steam, 
which  was  used  at  atmospheric  pressure,  that  is,  at  a temperature  not  exceeding  212°  F.,  being 
admitted  only  into  the  casing,  so  that  it  did  not  come  in  contact  with  the  objects  to  be  disin- 
fected. 

Experiments  were  first  made  with  vaccine  lymph,  dried  on  glass,  at  ordinary  temperatures. 
It  was  found  that  exposures  of  four  hours’  duration  to  180°  F.,  four  hours  to  140°  F.,  two  or  three 
hours  to  165°  F.,  two  hours  to  192°  F.  and  two  hours  to  150°  F.,  destroyed  the  activity  of  the 
vaccine  lymph. 

The  original  activity  of  the  lymph  was  proved  by  the  subsequent  successful  vaccination  of 
the  same  children  with  unheated  portions  of  the  same  lymph.  On  the  other  hand,  exposure  to  a 
temperature  of  120°  F.  for  three  hours  did  not  impair  the  activity  of  vaccine  lymph. 

With  reference  to  the  poison  of  typhus,  the  experiments  of  Dr.  Henry  were  as  follows : — 

Three  flannel  waistcoats  were  worn  successively,  each  for  several  hours,  by  a person  suffering 
from  contagious  typhus. 

No.  1,  after  one  and  three-quarters  hours’  exposure  to  a heat  of  205°  F.,  was  kept  for  two 
hours  close  under  the  nostrils  of  a person  engaged  in  writing,  who  was  fatigued  and  had  fasted 
for  eight  hours. 

No.  2,  after  similar  exposure  to  heat,  was  kept  for  twenty-six  days  in  an  air-tight  canister, 
and  was  then  placed  for  four  hours  close  to  the  face  of  the  same  person.  No  injurious  effects 
followed. 

It  was  not,  however,  shown  that  the  person  in  question  was  susceptible  to  the  disease. 

Similar  experiments  were  made  with  flannel  waistcoats  taken  from  the  bodies  of  scarlet  fever 
patients,  and  after  exposure  to  heat,  worn  by  children  who  were  known  not  to  have  previously 
suffered  from  the  disease.  None  of  these  children  contracted  scarlet  fever,  although  kept  under 
careful  observation,  in  order  that  no  slight  symptom  might  pass  unobserved. 

The  exposures  in  these  experiments  were  as  follows : 4 i hours  to  204°  F.,  2J  hours  to  irom 
200°  F.  to  204°  F.,  3 hours  to  204°  F.,  2 hours  to  200°  F.  and  1 hour  to  204°  F.  Here  ngaio, 
however,  the  proof,  for  obvious  reasons,  was  not  completed  by  causing  the  children  to  contract  the 
disease  by  wearing  garments  equally  infected  but  unheated.  So  far  as  these  experiments  of  Dr. 
Henry  go,  they  show  that  the  contagia  of  the  ordinary  infectious  diseases  aro  destroyed  by  dry 
heat  at  temperatures  below  the  boiling  point  of  water. 

A scries  of  experiments  on  the  degree  of  temperature  necessary  to  destroy  tho  activity  of  vac- 
cine lymph  was  made  by  Dr.  Baxter  (“Report  of  Medical  Officer  of  Privy  Council  and  bocal  ‘ 
Govermcnt  Board.”  New  serios,  1875,  pp.  228-229).  Tho  experiments  were  mado  with  dried 
lymph  on  wire  points.  These  were  attached  to  tho  bulb  of  a thermometer  which  was  enclosed  in 
a test-tube  in  such  a manner  as  not  to  touch  the  sides  of  the  tube.  The  test-tube  was  then  heated  i 
by  being  immersed  in  a water  bath.  Tho  duration  of  exposure  was  half  an  hour  in  all  cases. 
Ten  experiments  wero  made;  in  each  tho  hoatod  point  being  used  to  inoculate  three  places  on  one 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  371 


arm  of  a child,  while  three  other  points  charged  with  lymph  from  the  same  source  were  used  to 
inoculate  corresponding  places  on  the  other  arm. 

One  of  the  children  so  inoculated  did  not  return  for  inspection;  in  the  other  cases  it  was  found 
that  exposure  for  half  an  hour  to  a temperature  rising,  in  that  time,  from  167°  F.  to  176°  F.,  or 
to  a temperature  below  this,  did  not  impair  tho  activity  of  tho  lymph,  while  exposure  for  the  same 
length  of  time  to  a temperature  rising  from  185°  F.  to  194°  F.,  or  above,  destroyed  its  activity. 

The  difference  between  these  results  and  Dr.  Henry’s  is  explained  by  Dr.  Baxter  as  attribut- 
able to  the  difference  in  the  duration  of  the  exposures,  which,  in  Dr.  Henry’s  experiments,  was 
from  two  to  four  hours;  in  his  own,  only  half  an  hour,  degree  of  heat  and  length  of  exposure 
being  mutually  compensatory. 

In  Holland,  Drs.  Carsten  and  Coert  havo  made  a large  number  of  experiments  on  the  tempera- 
ture necessary  to  destroy  the  activity  of  calf  lymph.  They  find  that  lymph  heated  to  the  boiling 
point  of  water  is  invariably  sterilized. 

They  arrive  at  the  following  conclusions  : — 

1.  Animal  vaccine  heated  to  148°  F.  for  thirty  minutes  loses  its  potency. 

2.  Animal  vaccine  heated  to  125.6°  F.  for  thirty  minutes  does  not  lose  its  potency. 

3.  The  highest  heat  which  vaccine  can  support  without  losing  its  potency  is  probably 
between  125.6°  and  129.2°  F. 

The  experiments  of  Dr.  Henry  upon  the  degree  of  beat  necessary  to  destroy  the  contagion  of 
human  communicable  diseases  other  than  vaccinia  do  not  appear  to  have  been  repeated  by  sub- 
sequent investigators. 

Davaine  ( Comptee  Rendus,  September  29th,  1S73)  ascertained  that  the  blood  of  an  animal 
suffering  from  anthrax,  even  when  enormously  diluted  with  water,  when  inoculated  into  a Guinea- 
pig,  caused  its  speedy  death.  Such  dilutions  (1  in  10,000)  were  exposed  to  heat  and  subsequently 
inoculated,  when  it  was  found  that  their  virulence  was  destroyed  by  exposures  of  five  minutes  to 
131°  F.;  ten  minutes  to  122°  F.,  or  fifteen  minutes  to  a temperature  of  118.4°  F. 

When  the  blood  was  not  diluted,  it  required  for  complete  disinfection  an  exposure  of  fifteen 
minutes  to  a temperature  of  123.8°  F.  On  the  other  hand,  the  blood  when  previously  dried  over 
•chloride  of  calcium  retained  its  virulence  after  an  exposure  to  212°  F.  for  five  minutes.  Davaine 
states  that  the  virus  of  septicaemia  is  not  destroyed  by  a prolonged  ebullition. 

In  the  experiments,  however,  of  Dreyer  ( Archiv  fur  Experimentelle  Pathologie,  1874,  p.  1S2), 
rabbits  inoculated  with  septicaemic  blood  which  had  been  previously  mixed  with  a few  drops  of 
water  and  boiled  (it  is  not  stated  for  how  long)  remained  virile. 

Modern  discovery,  that  certain  communicable  diseases,  as  anthrax,  are  connected  with  the 
presence  of  microbes  in  the  blood  and  tissues,  a proposition  which,  from  analogy,  it  is  thought 
may  ultimately  be  found  applicable  to  all  diseases  of  the  same  class,  has  led  to  the  inference 
that  by  ascertaining  under  what  circumstances  microorganisms  or  the  more  resistant  among 
them  are  destroyed,  the  conditions  necessary  for  effectual  disinfection  may  be  learned. 

Upon  this  basis  an  extensive  and  important  series  of  researches  has  been  conducted  by  Koch 
.and  his  coadjutors  (Mittheilungen  aus  dem  Kaiserlichen  Gesundheitsamte,  Berlin,  1881).  The 
organisms  employed  in  these  researches  as  subjects  of  experiment,  comprise,  as  examples  of 
organisms  devoid  of  spores,  the  micrococcus  prodigioses,  and  the  bacterium  of  blue  pus,  and  of 
septicaemia,  and  as  examples  of  spore-bearing  kinds,  the  bacilli  of  anthrax  and  those  found  in 
hay  and  garden  earth.  The  samples  having  been  exposed  to  processes  of  disinfection,  the  subse- 
quent capacity  for  the  development  of  the  organisms  so  treated  was  tested  by  cultivation  on 
slices  of  potato,  or  on  gelatin  containing  blood  serum,  and  in  some  instances  by  inoculation  of 
animals.  Control  experiments  were  made  at  the  same  time  with  portions  of  the  material  not  so 
exposed. 

The  general  results  with  chemical  agents  was  to  show  the  comparative  or  entiro  inertness  as 
germicides  of  most  of  the  substances  commonly  received  as  disinfectants,  as  carbolic  and  sulphur- 
ous acids,  chlorido  of  zinc,  etc.  The  spores  of  bacillus  anthracis  wore  however  destroyed  by 
■exposure  for  one  day  to  the  action  of  the  watery  solution  of  either  of  tho  following  substances, 
namely,  chlorine,  bromine  (2  per  cent.),  iodine,  corrosive  sublimate  (1  per  cent.),  permanganate 
of  potash  (5  per  cent.),  and  arsenic  acid  (1  per  cent.). 

They  were  also  destroyed  after  longer  periods  by  the  following,  namely,  ether,  oil  of  turpen- 
tine, hydrochloric  acid,  chloride  of  iron  (five  percent.),  arsenious  acid  (one  per  cent.),  chloride 


372 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


of  lime  (five  per  cent.),  sulphide  of  ammonium,  formic  acid,  chloropicrin,  quinine  (one  per  cent, 
solution  in  water  with  hydrochloric  acid). 

It  appeared,  however,  that  the  destructive  power  upon  spores  in  the  form  of  vapor  is,  in 
some  cases,  increased  by  elevation  of  temperature.  Thus,  spores  of  the  bacilli  found  in  garden 
earth  were  killed  in  two  hours  by  exposure  at  a temperature  of  170°  F.  to  the  vapor  of  bisul- 
phide of  carbon,  although  neither  this  temperature  in  dry  air  nor  the  vapor  of  bisulphide  of  car- 
bon in  equal  concentration  at  ordinary  temperatures  had  any  destructive  action  on  spores. 

The  experiments  of  Koch  and  his  fellow-workers  were  in  hot  air,  made  in  apparatus  con- 
sisting of  a cylindrical  or  rectangular  vessel  of  cast  iron,  heated  by  steam  at  a pressure  up  to  six 
atmospheres  in  a closed  coil  of  copper  pipe.  The  results  of  these  experiments  are  thus  summed 
up  by  the  authors : — 

1.  Bacteria  free  from  spores  cannot  withstand  an  exposure  of  one  and  a half  hours  to  a tem- 
perature a little  over  212°  F.  in  hot  air. 

2.  Spores  of  mildews  require  for  destruction  a temperature  of  230°  F.  to  239°  F.,  for  one 
hour  and  a half. 

3.  Spores  of  bacilli  are  only  destroyed  by  remaining  three  hours  in  hot  air  at  284°  F. 

4.  In  hot  air  the  temperature  penetrates  so  slowly  into  articles  to  be  disinfected  that,  after 
three  or  four  hours’  heating  to  284°  F.,  articles  of  moderate  dimensions,  namely,  small  bundles  of 
clothes,  pillows,  etc.,  are  not  disinfected. 

5.  By  the  heating  for  three  hours  to  284°  F.,  necessary  for  the  disinfection  of  such  objects, 
most  materials  are  more  or  less  injured.  • 

The  results'obtained  with  steam  were  strikingly  superior  to  those  obtained  with  dry  heat.  It 
was  shown  that  an  exposure  of  five  minutes  to  steam  at  212°  F.  was  sufficient  to  kill  the  spores- 
of  the  anthrax  bacillus,  and  one  of  fifteen  minutes  to  kill  those  of  the  bacilli  contained  in  garden 
earth.  However,  the  penetration  of  heat  Into  articles  exposed  to  steam  took  place  far  more 
quickly  than  with  the  same  articles  when  exposed  to  dry  heat. 

Edwin  Waller,  ph.d.,  of  New  York,  has  published  valuable  tables  of  the  degrees  which  have 
been  found  sufficient  and  insufficient  for  the  destruction  of  various  contagia,  etc.  (See  Buck's 
“ Hygiene,”  Yol.  n,  p.  550.) 

Valliu  (“Traite  des  disinfectants  et  de  la  disinfection,”  1883,  p.  238),  in  reproducing  the 
table  of  Edwin  Waller,  remarks  that  many  of  the  assertions  therein  contained  are  open  to  ques- 
tion. On  the  other  hand,  Panum  (according  to  Rezl,  “ Prophylaxis  der  iibertragbaren  Krank- 
heiten,”  p.  85,  Vienna,  1881)  finds  that  septic  liquids  resist  much  higher  temperatures,  and  a heat 
of  320°  F.,  has  not  sufficed  to  take  away  their  infectious  properties. 

II.  EXPERIMENTS  ON  THE  DEGREE  AND  DURATION  OF  HEAT  NECESSARY  FOR  DISINFECTION. 

Dr.  Parsons  and  Professor  E.  Klein  have  made  an  elaborate  series  of  experiments  on  the- 
degree  of  heat  and  its  duration,  necessary  for  disinfection. 

Dr.  Klein  furnished  the  infective  materials,  and  also,  after  these  had  been  exposed  to  disin- 
fecting processes  by  Dr.  Parsons,  tested  the  results  by  inoculations  on  animals.  Control  inocu- 
lations with  unheated  portions  of  the  same  materials  were  also  in  all  cases  made. 

The  following  were  the  infective  materials  employed  : — 

1.  Blood  of  Guinea-pig,  died  of  anthrax,  containing  bacillus  anthracis  without  spores. 

2.  Pure  cultivation  of  bacillus  anthracis  in  rabbit  broth,  without  spores. 

3.  Cultivation  of  bacillus  anthracis  in  gelatin,  with  spores. 

4.  Cultivation  of  bacillus  of  swine  fever  (infectious  pneumo-enteritis  of  the  pig)  in  pork 
broth. 

5.  Tubercular  pus  from  an  abscess  in  a Guinea-pig  which  had  been  inoculated  with  tubercle. 

The  results  of  the  experiments  of  Drs.  Parsons  and  Klein  with  dry  heat,  as  far  as  regards 

anthrax,  are  far  more  favorable  as  to  its  efficacy  than  those  of  Koch.  It  appears  that  the  spores 
of  bacillus  anthracis  lose  their  vitality,  or  at  any  rate  their  pathogenic  quality,  after  exposure 
for  four  hours  to  a temperature  a little  over  the  boiling  point  of  water  (212°  to  216°  F.),  or  for 
one  hour  to  a temperature  of  245°  F.  Non-sporo  bearing  bacilli  of  anthrax  and  of  swine 
fever  were  rendered  inert  by  exposure  for  an  hour  to  a temperaturo  of  212°  to  218°  F.,  and 
even  five  minutes’  exposure  to  this  temperature  sufficed  to  dostroy  the  vitality  of  the  former 
and  impair  that  of  the  latter.  From  their  experiments  with  boiling  water,  Parsons  and  Klein 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  373 


conclude  that  the  contagia  of  the  ordinary  infectious  diseases  of  human  beings  are  not  likely  to 
retain  their  activity  after  boiling  for  a brief  period  in  water. 

The  results  of  the  experiments  of  Parsons  and  Klein  are  conclusive  as  to  the  destructive 
power  of  steam,  at  212°  F.,  upon  all  the  contagia  submitted  to  its  action;  these  results  are  in 
accordance  with  those  of  Koch,  Gaffky  and  Loefler;  and  it  may  bo  considered  as  established  that 
the  complete  penetration  of  an  object  by  steam  heat  for  more  than  five  minutes  is  sufficient  for 
its  thorough  disinfection. 

These  experiments  were  made  by  Drs.  Parsons  and  Klein  in  1884  and  1885,  and  the  valuable 
report  of  Dr.  Parsons  on  “ Disinfection  by  Heat,”  containing  these  experiments,  has  been  pub- 
lished in  the  “ Seventeenth  Annual  Report  of  the  Local  Government  Board,  1884-1885.”  Sup- 
plement containing  the  Report  of  the  Medical  Officer,  pp.  21S-304. 

In  addition  to  the  experiments  cited,  this  report  contains  experiments  and  observations  on — 
“ The  penetration  of  heat  into  articles  submitted  to  disinfection.” 

“On  the  liability  to  injury  of  articles  disinfected  by  heat.” 

“ On  the  practical  utility  of  disinfection  by  heat.” 

“ On  the  different  forms  of  apparatus  for  disinfection  by  heat.” 

The  apparatus  for  disinfection  by  heat  are  thus  classified  : — 

(a)  By  hot  ah — 

1.  Apparatus  in  which  the  heat  is  applied  to  the  outside  of  the  chamber  and  the  products  of 

combustion  do  not  enter  the  interior. 

2.  Apparatus  in  which  the  heated  products  of  corrfbustion  enter  the  interior. 

3.  Apparatus  heated  by  steam  or  hot  water  circulating  in  closed  pipes. 

4.  Apparatus  in  which  air  previously  heated  is  blown  into  the  chamber. 

(h)  By  steam — 

5.  By  a current  of  free  steam. 

6.  By  steam  confined  in  a chamber  at  pressures  above  that  of  the  atmosphere. 

The  apparatus  described  under  the  first  class  are  Nelson’s,  Fraser’s,  Dr.  Heron  Roger’s, 
Dr.  Longstaff’s,  Taylor’s  and  Bradford’s,  also  Dr.  Scott’s,  in  the  form  heated  by  coal.  Under  the 
second  class  are  described  Washington  Lyon’s  Steam  Disinfector,  Benham  & Son’s  Steam  Dis- 
infector, Branford’s  Steam  Disinfector. 

THE  FOLLOWING  IS  A SUMMARY  OP  THE  VALUABLE  REPORT  OF  DR.  PARSONS  ON  DISINFECTION  BY 

HEAT. 

“Fourteenth  Annual  Report  of  the  Local  Government  Board,  1884-1885.  Supplement  con- 
taining Report  of  Medical  Officer  for  1884,  pp.  218-304.”  London,  1885. 

1.  With  the  exception  of  spore-bearing  cultivations  of  the  bacillus  of  anthrax,  all  the  infective 
materials  experimented  upon  were  destroyed  by  ten  hours’  exposure  to  dry  heat  of  220°  F.,  or 
five  minutes’  exposure  to  steam  at  212°  F.  Spores  of  bacillus  anthrax  required  for  destruction 
four  hours’  exposure  to  dry  heat  of  220°  F.,  or  one  hour’s  exposure  to  dry  heat  of  245°  F.,  but 
were  destroyed  by  five  minutes’  exposure  to  a heat  of  212°  F.,  in  steam  or  boiling  water.  It 
may  be  assumed  that  the  contagia  of  the  ordinary  infectious  diseases  of  mankind  are  not 
likely  to  withstand  an  exposure  of  an  hour  to  dry  heat  of  220°  F.,  or  one  of  five  minutes  to 
boiling  water  or  steam  of  212°  F. 

2.  Dry  heat  penetrates  very  slowly  into  bulky  and  badly  conducting  articles,  as  of  bedding  and 
clothing;  the  time  commonly  allowed  for  the  disinfection  of  such  articles  being  insufficient  to 
allow  an  adequate  degree  of  heat  to  penetrate  into  the  interior. 

Steam  penetrates  far  more  rapidly  than  dry  heat,  and  its  penetration  may  be  aided  by 
employing  it  under  pressure,  the  pressure  being  relaxed  from  time  to  time,  so  as  to  displace  the 
cold  air  in  the  interstices  of  the  material. 

In  hot  air  the  penetration  of  heat  is  aided  by  the  admixture  of  steam,  so  as  to  moisten  the 
air,  but  hot  moist  air  did  not  appear  to  have  a greater  destructive  effect  upon  spores  of  anthrax 
bacilli  than  dry  heat. 

3.  Scorching  begins  to  occur  at  different  temperatures  with  different  materials,  white  wool 
being  soonest  affected.  It  is  especially  apt  to  occur  whero  the  heat  is  in  the  radiant  form.  To 
avoid  risk  of  scorching,  the  heat  should  not  bo  allowed  much  to  exceed  250°  F.,  and  even  this 
temperature  is  too  high  for  white  woolen  articles. 


374 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


4.  By  a heat  of  212°  and  upward,  whether  dry  or  moist,  many  kinds  of  stains  are  fixed  in 
fabrics  so  that  they  will  not  wash  out.  This  is  a serious  obstacle  in  the  way  of  the  employment 
of  heat  for  the  disinfection  previous  to  the  washing  of  linen,  etc.,  soiled  by  the  discharges  of  the 
siok. 

5.  Steam  disinfection  is  inapplicable  in  the  case  of  leather,  or  of  articles  which  will  not  bear 
wetting.  It  causes  a certain  amount  of  shrinkage  in  textile  materials,  about  as  much  as  an 
ordinary  washing.  The  wetting  effect  of  the  steam  may  be  diminished  by  surrounding  the 
chamber  with  a jacket  containing  steam  at  a higher  pressure,  so  as  to  superheat  the  steam  in  the 
chamber. 

6.  For  articles  that  will  stand  it,  washing  in  boiling  water  (with  due  precautions  against 
re-infection)  may  be  relied  on  as  an  efficient  means  of  disinfection.  It  is  necessary,  however, 
that  before  boiling,  the  grosser  dirt  should  be  removed  by  a preliminary  soaking  in  cold  water. 
This  should  be  done  before  the  linen  leaves  the  infected  place. 

7.  The  objects  for  which  disinfection  by  dry  heat  or  steam  is  especially  applicable  are  such 
as  will  not  bear  boiling  in  water,  e.y.,  bedding,  blankets,  carpets  and  cloth  clothes  generally. 

8.  The  most  important  requisites  of  a good  apparatus  for  disinfection  by  heat  are  (a)  that  the 
temperature  in  the  interior  shall  be  uniformly  distributed;  (6)  that  it  shall  be  capable  of  being 
maintained  constant  for  the  time  during  which  the  operation  extends;  and  (c)  that  there 
shall  be  some  trustworthy  indication  to  the  actual  temperature  of  the  interior  at  any  given 
moment.  Unless  these  conditions  be  fulfilled,  there  is  risk,  on  the  one  hand,  that  articles 
exposed  to  heat  may  be  scorched,  or  on  the  other  hand,  that  through  anxiety  to  avoid  such 
an  accident  the  opposite  error  may  be  incurred,  and  that  the  articles  may  not  be  sufficiently 
heated  to  insure  their  disinfection. 

9.  In  dry-heat  chambers  the  requirement  (a)  is  often  very  far  from  being  fulfilled,  the 
temperature  in  different  parts  of  the  chamber  varyiug  sometimes  by  as  much  as  100°.  This  is 
especially  the  case  in  apparatus  heated  by  the  direct  application  of  heat  to  the  floor  or  sides  of 
the  chamber.  The  distribution  of  temperature  is  more  uniform  in  proportion  as  the  source  of 
heat  is  removed  from  the  chamber,  so  that  the  latter  is  heated  by  currents  of  hot  air  rather  than 
by  radiation. 

10.  In  chambers  heated  by  gas,  when  once  the  required  temperature  has  been  attained,  but 
little  attention  is  necessary  to  maintain  it  uniform,  and  in  the  best  made  apparatus  this  is  auto- 
matically performed  by  a thermo-regulator.  On  the  other  hand,  in  apparatus  heated  by  coal  or 
coke,  the  temperature  continually  tends  to  vary,  and  can  only  bo  maintained  uniform  by  constant 
attention  on  the  part  of  the  stoker. 

11.  In  very  few  hot-air  chambers  did  the  thermometer  with  which  the  apparatus  was  provided 
afford  a trustworthy  indication  of  the  temperature  of  the  interior;  in  some  instances  there  was  an 
error  of  as  much  as  100°  F.  This  was  due  to  the  thermometer,  for  reasons  of  safety  and  accessi- 
bility, being  placed  in  the  coolest  part  of  the  chamber,  and  to  the  bulb  being  enclosed,  for  protec- 
tion, in  a metal  tube,  which  screens  it  from  the  full  access  of  heat.  The  difficulty  may  be  over- 
come by  using,  instead  of  a thermometer,  a pyrometer,  actuated  by  a metal  rod  extending  across 
the  interior  of  the  chamber. 

12.  In  steam  apparatus  the  three  requirements  above  mentioned  are  all  satisfactorily  met,  and 
for  this  reason,  as  well  as  on  account  of  the  greater  rapidity  and  certainty  of  action  of  steam, 
steam  chambers  are,  in  Dr.  Parson’s  opinion,  greatly  preferable  to  those  in  which  dry  heat  is 
employed. 

13.  Without  wishing  to  give  the  preference  to  one  maker  over  another,  I may  mention  that 
of  tho  apparatus  heated  by  coal,  Bradford’s  newer  machine;  of  those  heated  by  gas,  the  Notting- 
ham self-regulating  disinfecting  apparatus;  and  of  those  employing  steam,  Lyon’s  patent  steam 
disinfector,  in  Dr.  Parson’s  experiments,  gave  tho  best  results  of  any  in  their  respective  classes. 

14.  It  is  important  that  the  arrangement  of  tho  apparatus,  tho  method  of  working,  and  the 
mode  of  conveyance  to  and  fro  should  be  such  as  to  obviate  risk  of  articles  which  have  been  sub- 
mitted to  disinfection  coming  into  contact  with  others  which  are  infected. 

Tho  preceding  facts  present  a comprehensive  view  of  tho  present  state  of  our  knowledge  with 
reference  to  heat  as  a disinfecting  agent. 

The  mode  of  its  application,  as  well  as  the  capacity  and  arrangement  of  tho  apparatus,  will* 
of  course,  depend  largoly  upon  tho  size  and  resources  of  tho  quarantine  station  or  hospital. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


375 


The  value  of  heat  as  a disinfectant  is  now  so  well  understood  and  tho  facilities  for  its  use  so 
great  that  all  quarantine  stations,  hospitals  and  inspection  stations  for  the  detention  of  passengers 
along  lines  of  travel,  and  especially  along  railroads,  should  be  supplied  with  the  necessary  appli- 
ances for  the  application  of  both  dry  heat  and  steam. 

CARBOLIC  ACID  : ITS  ANTISEPTIC  AND  GERMICIDE  POWERS.  HISTORY  OF  CARBOLIC  ACID  DISINFEC- 
TION IN  EUROPE  AND  AMERICA,  AND  MORE  ESPECIALLY  IN  NEW  ORLEANS,  LOUISIANA. 

Carbolic  Acid  ( Phenic  Acid,  Phenol,  Phenyl  Alcohol,  or  Coal  Tar  Creosote):  its  Antiseptic 
Properties. — An  important  advance  in  sanitary  and  medical  science  was  made  when  the  anti- 
septic and  disinfectant  virtues  of  carbolic  acid  were  recognized  and  practically  applied. 

Such  compounds  as  coal,  bitumen,  asphalt  and  petroleum,  which  contain  carbolic  acid,  or  com- 
pounds closely  allied  thereto  in  nature  and  properties,  are  widely  spread  over  the  globe,  and  have 
been  used  for  ages  as  antiseptics.  The  Egyptians  employed  resinous  and  bituminous  compounds 
in  embalming  their  mummies;  resinous  aromatic  substances,  incense  and  tar  were  burnt  by  the 
Greeks  and  Jews  to  arrest  and  remove  pestilential  diseases;  tar  and  bitumen  were  used  by  the 
ancients  for  the  preservation  of  wood,  and  especially  tho  timbers  of  boats  and  ships,  from  decay 
and  the  ravages  of  insects  and  marine  worms ; and  some  of  these  compounds  were  employed  by 
the  Romans  to  arrest  vinous  and  acetous  fermentation  in  the  preparation  of  wine. 

The  Romans  sometimes  place  I their  fermenting  wine  in  vessels  lined  with  pitch,  or  threw 
powdered  pitch  into  the  fluid,  or  adopted  the  simple  expedient,  the  rationale  of  which  was  prob- 
ably identical,  of  plunging  therein  a blazing  pine  tprch,  and  there  is  no  doubt  that  in  these 
operations  carbolic  acid,  in  the  guise  of  tar,  controlled  the  vinous  and  prevented  the  acetous  fer- 
mentation. 

Wood  steeped  in  asphalt,  or  coated  with  this  substance,  will  last  for  centuries,  as  has  been 
clearly  shown  by  the  results  of  the  experiments  of  the  Assyrians  and  Egyptians.  The  experi- 
ence of  four  thousand  years  has  shown  that  asphalt  is  one  of  the  most  indestructible  of  all  sub- 
stances, and  at  the  same  time  that  it  is  the  most  powerful  of  all  preservers  of  animal  and  vege- 
table substances.  Not  only  are  the  Egyptian  mummies  and  burial  cases,  which  have  been  steeped 
in  hot  asphalt,  in  a state  of  preservation  at  the  present  time,  but  the  delicate  fabrics  surrounding 
the  mummies  have  been  preserved  in  their  original  strength  and  beauty.  Asphalt  has  been  used 
by  both  ancient  and  modern  nations,  from  the  time  that  Noah  fulfilled  the  divine  command  to 
“pitch”  the  ark  “within  and  without  with  pitch,”  for  the  preservation  of  ships  and  boats  and 
wooden  structures  from  decay.  The  first  structure  of  any  magnitude  erected  after  the  flood— the 
Temple  of  Belus — was  cemented  with  bitumen;  and,  according  to  Herodotus,  asphalt  was  used  as 
a cement  for  the  union  and  preservation  of  the  bricks  composing  the  immense  walls  and  temples 
of  Babylon.  The  Spaniards  discovered  in  the  West  Indies,  three  centuries  ago,  the  important 
fact  that  the  asphalt  with  which  Cuba  and  Trinidad  abound  was  the  best  and  only  preservative 
of  the  bottoms  of  their  ships  against  decay  and  the  destructive  action  of  marine  animals,  with 
which  the  warm  salt  water  abounded.  The  whole  country  around  Havana  is  impregnated  with 
bituminous  matter;  even  the  solid  quartz,  the  serpentine  rocks  and  the  veins  of  chalcedony  have 
cells  and  cavities  filled  with  liquid  pitch  or  asphalt.  In  the  Bay  of  Havana,  the  shore  at  low 
water  abounds  with  asphalt  and  bituminous  shales,  in  sufficient  quantity  for  paying  of  vessels.  It 
is  stated  that  in  buccaneering  times  signals  used  to  bo  made  by  firing  masses  of  this  chapapote, 
whose  dense  columns  of  smoke  could  be  recognized  at  great  distances  and  served  as  signals 
to  vessels  at  sea;  and  it  is  even  a matter  of  history  that  Havana  was  originally  named,  by  tho 
earlier  visitors  and  settlers,  Carene,  “for  there  we  careened  our  ships,  and  we  pitched  them  with 
the  mineral  tar  which  we  found  lying  in  abundance  upon  the  shores  of  this  beautiful  bay.” 

In  1854,  I instituted  an  extended  series  of  experiments  upon  the  antiseptic  properties  of 
various  substances,  and  have  as  opportunity  served  continued  them  up  to  the  present  moment. 

The  first  series  of  experiments  related  to  the  preservation  of  animal  structures;  tho  second 
related  to  the  arrest  of  decomposition  in  gangrenous  ulcers,  cancers  and  gunshot  wounds ; and 
the  third  series  related  to  the  preservation  of  wood  from  decay,  and  the  destructive  action  of 
marine  animals.  A large  number  of  the  specimens  thus  preserved  from  decay  are  at  the  present 
time  deposited  in  the  Museum  of  the  Medical  Department  of  tho  Tulane  University  of  Louisiana. 
One  of  the  most  striking  specimens  consists  of  both  feet  of  a man  whose  lower  extremities  were 
frozen  in  the  swamps  of  Louisiana. 


376 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Not  only  was  tlio  decomposition  caused  by  the  gangrene  arrested  in  this  case,  but  the  feet 
exhibit  the  black,  gangrenous  portions,  the  lines  of  demarkation  and  the  sound  skin. 

It  was  determined  by  these  experiments,  that  it  was  possible  to  preserve  not  only  limbs  and 
organs,  but  also  entire  animals,  by  means  of  various  antiseptics,  as  arsenious  acid,  bichloride  of 
mercury,  and  carbolic  acid. 

Wood  subjected  to  the  action  of  hot  asphalt  and  carbolic  acid  not  only  resisted  decay,  but  also, 
when  immersed  in  the  waters  of  the  Gulf  of  Mexico,  resisted  the  action  of  the  marine  worm, 
( Teredo  Navalis)  which  destroys  annually  an  immense  amount  of  property  in  all  seaports  aod 
along  all  coasts  in  warm  climates. 

The  late  General  Braxton  Bragg,  who  was  an  engineer,  took  the  liveliest  interest  in  the  method 
of  preserving  wood  from  decay  and  the  action  of  the  Teredo  Navalis,  carried  out  a careful  series 
of  experiments,  by  the  aid  of  the  United  States  engineers  and  the  civil  engineers  of  the  more 
important  railroads,  upon  the  samples  of  wood  prepared  by  myself;  and  in  all  cases  the  wood 
immersed  in  Mobile  Bay,  Pensacola  Harbor,  Bay  St.  Louis,  Galveston  Harbor  and  Matagorda 
Bay,  resisted  decay  and  the  action  of  marine  animals. 

History  of  the  Discovery  of  Carbolic  Acid,  and  its  Application  to  Medical  and  Sanitary 
Science. — Carbolic  acid  (Phenol,  hydrate  of  phenol,  phenylic  alcohol,  phenic  acid,  coal  tar, 
creasote)  was  discovered  by  Runge  in  1834,  who  experimentally  determined  its  disinfecting 
properties;  in  1844,  M.  Bayard  introduced  a powder  as  a disinfector  in  which  coal  tar  was  an 
ingredient;  in  1851,  Mr.  Calvert,  of  Manchester,  made  many  experiments  with  carbolic  acid, 
using  it  for  preserving  flesh  from  putrefaction,  injecting  it  into  the  arteries  of  dead  animals,  and 
demonstrating  its  power  to  prevent  putrefaction,  and  to  check  fermentation. 

Mr.  Robert  Angus  Smith,  in  his  valuable  work  on  Disinfectants  and  Disinfection,  published 
in  1869,  says,  “ The  use  of  carbolic  acid  on  a large  scale  was  first  brought  prominently  forward 
by  myself  and  Mr.  McDougal,  so  far  as  I know,  about  fourteen  years  ago,  but  all  its  essential 
properties  were  known  before.  Mr.  McDougal,  by  using  it  in  McDougal’s  powder,  has  made  it 
famous,  and  its  fame  has  caused  a similar  powder  to  be  made  in  other  countries,  and  by  other 
persons.  He  used  it  also  for  wounds  and  the  destruction  of  insects. 

“ Eor  the  preservation  of  manure,  it  is  as  marvelous  as  for  the  preservation  of  meat,  while  it 
does  not  destroy  the  fertilizing  power,  but  preserves  all  the  elements,  as  if  frozen,  from  all 
change. 

“ It  was  recommended  by  the  author  (Robert  Angus  Smith)  for  the  prevention  of  decom- 
position in  sewers  and  in  sewer  rivers,  until  they  could  be  more  thoroughly  purified.  In  a 
treatise  on  ‘Suvern’s  system,’  by  Dr.  Hubert  Grouven,  the  same  mode  of  purifying  sewers  is 
recommended,  and  said  to  be  on  trial  in  Leipzig.  The  mixture  used  is  a little  different;  1 pound 
of  melted  chloride  of  magnesium;  3 pounds  of  lerni;  £ pound  coal  tar. 

“ Mr.  McDougal  has  long  used  tar-oil  and  lime  for  the  land  at  Carlisle.  I still  think  that  it 
would  be  better  to  pour  this  on  the  streets,  and  to  let  it  disinfect  all  that  is  found  there,  running 
it  then  into  the  sewers,  and  preventing  putrefaction  there,  as  it  is  better  to  prevent  than  to 
interrupt  the  formation  of  unwholesome  gases. 

“ The  great  advantage  of  carbolic  acid  is  that  itisa  liquid,  slightly  volatile;  it  is  therefore  easy 
to  throw  it  down  anywhere,  and  to  cause  it  to  penetrate  into  every  corner  of  a building,  or  to  fill 
the  air  of  the  neighborhood.”  p.  63. 

It  is  evident  from  the  preceding  statement  that  the  investigations  on  the  value  of  carbolic 
acid  as  a disinfectant  were  commenced  by  Mr.  Robert  Angus  Smith  about  the  year  1854. 

M.  le  Beuf,  of  Bayonne,  about  1859,  employed  crude  carbolic  acid  in  the  form  of  a saponaceous 
emulsion,  and  associated  with  his  labors  M.  Lemaine,  of  Paris.  These  investigators  established 
the  value  of  the  emulsion  as  an  application  to  gangrenous  ulcers.  About  the  same  time  Kiichen- 
meister,  of  Dresden,  used  carbolic  acid  in  medical  and  surgical  practice,  and  in  arresting 
putrefaction  and  preventing  the  manifestation  of  fungi. 

In  1860  M.  Lcmairo  established  the  value  of  coal-tar  applications  in  the  treatment  of  wounds, 
and  demonstrated  that  carbolic  acid  was  the  active  agent  in  effecting  the  changes;  and  in  an 
elaborate  treatise  published  in  1863,  he  narrated  a series  of  investigations  in  which  carbolic  acid 
was  employed  as  a means  for  tho  destruction  of  low  forms  of  animal  and  vegetable  life,  as  a pre- 
ventive of  fermentation  and  putrefaction,  as  an  external  application  in  cases  of  ulcerating  and 
suppurating  surfaces,  as  well  as  an  internal  remedy  in  zymotic  and  other  diseases. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  377 


Coal  tar  was  used,  in  the  treatment  of  gunshot  wounds,  to  a limited  extent,  by  the  Southern 
{ Confederate)  surgeons  during  tho  American  civil  war,  1861-1865. 

The  occurrence  of  cattle  plague  in  England,  in  1865,  gavo  an  impetus  to  the  study  of  disin- 
fectants, and  important  additions  to  sanitary  science  were  made  by  the  investigations  of  Dr. 
Angus  Smith  and  Mr.  Crooks.  The  appendix  to  the  “ Royal  Commissioners’  Report”  on  the  cattle 
plague  contains  the  following  : — 

“ According  to  the  principles  laid  down,  the  air  must  be  treated,  and  where  there  is  no  disease 
there  is  only  a secondary  use  in  treating  anything  besides  the  air.  Several  cow-houses  have 
been  treated  with  carbolic  acid  with  very  excellent  results.  The  mode  has  been,  first,  to  remove 
from  the  floor  the  mass  of  manure  which  too  often  adheres  to  it ; secondly,  to  sprinkle  the  floor 
with  strong  carbolic  or  cresylic  acid.  Next  to  wash  the  walls,  beams  and  rafters,  and  all  that  is 
visible  in  the  cow-house,  with  lime,  in  which  is  put  some  carbolic  acid,  one  to  fifty  of  the  water 
used,  or  with  strong  carbolic  acid  alone.  Next  to  make  a solution  containing  one  of  carbolic 
acid  or  cresylic  acid  to  100  of  water,  or,  perhaps  still  better,  sixty  of  water,  and  to  water  the  yard 
and  fold  until  the  whole  space  smells  strongly  of  the  acid.  Only  a few  farms  have  been  treated 
in  this  way,  so  far  as  I know,  but  in  each  it  has  been  successful.  It  may  be  well  to  give  tho  cat- 
tle a little  of  the  weak  solution  of  carbolic  acid,  but  this  has  not  been  so  fully  tried  as  the 
external  use.  The  washing  of  the  moutji  and  entire  animal  with  the  weak  solution  may  be 
attended  with  good  results,  especially  in  the  early  stage  of  disease.” 

Mr.  Crooks  made  elaborate  experiments  on  carbolic  acid,  and  in  his  Report  gives  details  of 
experiments  in  which  this  acid  was  injected  directly  into  the  blood  vessels  of  cattle.  Although 
the  experiments  with  the  injection  of  carbolic  acid  into  the  blood  were  too  few  to  permit  of  any 
practical  conclusions  as  to  its  therapeutic  effects  when  administered  in  this  manner,  nevertheless, 
Mr.  Crooks  demonstrated  that  it  reduces  the  animal  temperature,  and  does  not  necessarily  prove 
fatal  when  injected  in  the  amount  of  one  part  to  10,000  parts  of  blood. 

In  1865  Professor  Lister  commenced  the  employment  of  carbolic  acid  as  an  application  to 
wounds  and  abscesses  attended  with  suppuration,  and  obtained  results  which  confirmed  the 
accuracy  of  those  previously  announced  by  Lemaire  and  others. 

Mr.  Lister  has  continued  his  investigations  up  to  the  present  time,  and  by  his  energetic  and 
intelligent  advocacy  of  carbolic  acid  for  the  treatment  of  wounds  in  England,  Prance,  Germany 
and  America,  has  succeeded  in  directing  the  minds  of  the  profession  to  the  value  of  this  ageut, 
and  rendered  popular  the  so-called  antiseptic  system  in  surgery.  It  would  be  foreign  to  our  pur- 
pose to  adduce  in  this  connection  the  mass  of  testimony  recorded  by  Professor  Lister  and  others 
as  to  the  value  of  carbolic  acid  as  a local  application  to  wounds. 

Value  of  Carbolic  Acid  as  a Disinfectant  and  Antiseptic  in  Asiatic  Cholera  and  Cattle 
Plagues. — During  the  outbreak  of  cholera  in  1866,  carbolic  acid  was  put  to  a practical  test,  both 
in  England  and  America,  and  the  reports  of  the  medical  officers  of  health  testifying  to  its  efficacy 
may  be  found  in  the  Registrar-General’s  Report  on  the  cholera  epidemic  of  1866  in  England. 

The  intelligent  and  systematic  use  of  carbolic  acid  and  other  disinfectants  in  North  America 
for  the  arrest  of  cholera  and  other  contagious  diseases  was  inaugurated  by  the  Metropolitan 
Board  of  Health  of  New  York  during  the  cholera  epidemic  of  1866;  and  the  marked  success 
achieved  in  the  limitation  of  the  ravages  of  the  disease  was  largely  due  to  the  untiring  labors 
of  the  eminent  American  sanitarian,  Dr.  Elisha  Harris. 

The  prevalence  of  cholera  in  various  parts  of  Europe,  and  tho  almost  absolute  certainty  of 
its  appearance  in  America  during  the  year  1866,  stimulated  the  Metropolitan  Board  of  Health 
to  great  activity,  immediately  upon  its  organization,  to  prejraro  the  Metropolitan  District  for  the 
arrival  of  the  epidemic.  Under  the  direction  of  the  Board,  a disinfectant  depot  and  laboratory 
was  established  in  a building,  No.  308  Mulberry  street,  immediately  adjacent  to  the  central 
office,  and  placed  under  experienced  and  able  assistants.  Tho  laboratory  was  constantly  used  for 
experiments  in  the  use  and  combination  of  various  disinfectants,  and  the  men,  for  tho  proper  and 
faithful  application  of  the  same.  This  duty,  as  the  season  advanced,  became  of  a most  laborious, 
and  often  hazardous,  character.  The  men  wore  constantly  visiting  infected  districts,  entering  tho 
houses  there  and  handling  bedding  and  clothes  soiled  by  the  dejections  of  cholera  patients;  they 
were  also  obliged  to  disinfect  all  bodies  dead  of  cholera,  and  frequently  to  place  them  in  coffins 
and  remove  them  to  the  morgue. 

Immediately  upon  the  arrival  of  the  steamship  Atalanta,  with  its  company  of  cholera  sick, 


378 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


in  the  Bay  of  New  York,  in  November,  1865,  Dr.  Elisha  Harris,  by  request  of  the  Citizens’ 
Council  of  Hygiene,  prepared  a memorandum  on  preventive  measures  against  the  epidemic, 
from  which  wo  extract  the  following  paragraphs  concerning  cholera  disinfection.* 

“ Let  the  excremcntitious  matters  from  the  sick  be  disinfected  in  the  vessel  as  soon  as  voided, 
by  means  of  carbolate  of  lime,  su  phate  or  proto-chloride  of  iron,  coal  tar,  carbolic  acid,  or  per- 
manganate of  potash,  and  let  no  well  person  directly  use  the  privy  into  which  such  materials  are 
emptied  while  cholera  is  prevailing.  Whenever  practicable,  let  the  evacuated  materials  be 
deeply  buried  in  the  earth,  and  immediately  covered  with  quicklime  or  coal  tar  and  gravel. 

“ Let  all  the  vessels  and  clothing  that  are  used  by  the  patients  bo  immediately  cleansed  with 
boiling  water  and  soap,  or  alkaline  chlorides,  or  permanganates. 

“ Preserve  the  utmost  degree  of  personal  cleanliness  of  the  sick  and  their  attendants. 

“ To  absorb  moisture  and  putrid  fluids,  use  fresh  stone  lime,  finely  broken ; sprinkle  it 
abundantly  on  the  place  to  be  dried ; or  for  damp  rooms  place  a large  number  of  plates  filled 
with  the  lime  powder  and  not  with  the  kalsomine. 

“ To  absorb  putrid  gases  use  charcoal  powder.  The  coal  must  be  dry  and  fresh,  and  should 
be  combined  with  lime. 

“To  give  off  chlorine,  to  absorb  putrid  effluvia  and  to  stop  putrefaction,  use  chloride  of  lime, 
as  lime  is  used;  and  if  in  cellars  and  close  rooms  the  chlorine  gas  is  wanted,  pour  diluted  sul- 
phuric acid,  or  muriatic  acid,  upon  your  plates  of  chloride  of  lime  occasionally,  and  add  more  of 
the  chloride. 

“ To  disinfect  the  discharges  from  cholera  patients  and  to  purify  privies  and  drains,  dissolve 
ten  pounds  of  copperas  in  a pailful  of  water,  and  pour  a gallon  or  two  of  this  strong  solution 
into  the  privy,  and  water-closet  or  drain,  every  hour,  if  cholera  discharges  have  been  thrown  into  a 
these  places;  but  for  ordinary  use,  to  keep  privies  from  becoming  offensive,  pour  a pint  of  this 
solution  into  every  water-closet,  pan  or  privy  seat  every  night  or  morning.  Bed-pans  and  chamber 
vessels  are  best  disinfected  in  this  way,  by  a teaeupful.  of  the  copperas  solution.  Add  the  same 
quantity  of  carbolic  fluid  (diluted  carbolic  acid),  or  coal-tar  powder,  to  insure  permanent  disin- 
fection ; chloride  of  zinc,  or  proto-chloride  of  iron,  may  be  substituted  for  the  sulphate  of  iron. 

“ Permanganate  of  potassa  may  be  used  to  disinfect  clothing  and  towels  from  cholera  and  fever 
patients  during  the  night,  or  when  such  articles  cannot  be  instantly  boiled.  Throw  the  soile  l 
articles  immediately  into  a small  tub  of  water,  in  which  there  has  been  dissolved  an  ounce  of 
permanganate  salt  to  every  two  gallons  of  water,  until  the  clothing  is  boiled; 'and  see  to  it  that 
the  permanganate  salt  is  added  in  just  sufficient  quantity  to  keep  up  a purple  or  red  color  in  the 
water  that  covers  the  clothing.  A pint  of  Labarraque’s  solution  of  chlorinated  soda  may  be 
used  for  the  same  purpose  in  the  tub  of  water  if  the  clothing  is  to  be  soon  boiled,  but  must  not 
be  trusted  for  permanent  disinfection.  Either  of  these  substances  may  bo  used  in  cleansing  the 
soiled  parts  of  the  body  of  the  sick  or  dead  persons,  or  may  be  used  in  bed-pans,  etc.  The 
permanganate  solution  will  instantly  disinfect  and  deodorize  whatever  it  touches,  but  its  action 
continues  only  while  it  gives  a purple  or  reddish  color.  , 

“ Carbolic  acid  and  the  coal-tar  disinfectants  are  the  most  efficient  and  permanent  antiseptics,  j 
The  crystallized  acid  (Cortly)  will  dissolve  in  one  hundred  times  its  own  weight  of  water.  A 
tablespoonful  of  the  solution  will  disinfect  a chamber  vessel.  The  fluid  acid  (cheap),  seventy 
per  cent,  strength  of  crystallized,  is  most  valuable  for  common  use.  Dilute  it  in  twenty-five,  fifty, 
or  more  parts  of  the  iron  solutions  for  fluid  use,  or  in  fine  quicklime  or  saw-dust  for  use  in  foul 
surfaces  and  heaps. 

“ To  disinfect  discharges  from  cholera  patients,  privies,  water-closets,  garbage  tubs  and  foul 
heaps,  or  surfaces,  use  the  strongest  of  the  coal-tar  or  carbolic  powders,  which  are  powerful  y 
antiseptic.  Those  which  contain  a large  amount  of  some  proto-salt  of  iron,  and  the  most 
carbolic  acid,  are  best.  For  disinfecting  cholera  always  use  one  of  the  soluble  salts  of  iron  o.‘  : 
zinc,  as  mentioned  in  this  memorandum,  whatever  olso  is  employed.” 

Never  use  chlorine,  chlorides,  or  the  permanganate  of  potash  with  carbolic  acid  disinfectants . 

Let  closets  and  bedrooms  be  cleansed,  dried  and  ventilated.  Beds  and  bedding  must  bo  fre- 
quently ventilated  in  the  sun. 

Whatever  soiled  clothing  can  be  boiled  should,  if  possible,  as  soon  as  removed,  bo  thrown  into 


* “ Annual  Report  of  the  Metropolitan  Board  of  Health,  18SG,”  pp.  206-217. 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  379 


boiling  water  and  bo  kept  boiling  an  hour  or  two.  While  waiting  the  boiling,  keep  all  the 
cholera-soiled  clothing  covered  in  the  disinfecting  permanganate  water,  or,  if  that  is  not  at  hand, 
use  the  chlorinated  solution.  Whatever  articles  have  received  the  infectivo  matter  of  cholera 
and  cannot  be  immediately  disinfected  by  such  means,  or  by  sulphurous  fumigation,  should  be 
destroyed  by  fire. 

Let  it  not  be  forgotten  that  all  the  discharges  from  the  bowels  and  the  stomach  of  the  cholera 
sick  must  be  immediately  disinfected  by  the  means  specified  for  this  purpose. 

Never  cast  the  discharges  from  the  sick  into  a privy  or  upon  the  surface  of  the  ground,  but 
into  some  privy  or  water-closet  that  is  not,  for  the  time  being,  frequented,  or  into  a specially  pre- 
pared pit.  And  whether  cast  into  a privy  or  earth-pit,  or  elsewhere,  the  choleraic  discharges,  at 
every  stage  of  the  disease,  from  the  first  diarrhoea  to  the  final  collapse,  must  be  disinfected  as 
soon  as  voided,  and  be  impregnated  with  destructive  chemicals  when  cast  away. 

Fumigation  of  Infected  Houses. — In  any  room,  house  or  ship,  where  the  infection  of  cholera 
exists,  or  is  liable  to  exist,  after  cleansing,  fumigation  should  be  practiced  with  sulphurous  acid  gas, 
by  burning  a few  ounces  of  sulphur  upon  a dish  of  red-hot  embers,  or  with  nitrous  acid  fumes,  by 
pouring  three  ounces  of  concentrated  nitric  acid  over  an  ounce  of  fine  copper  shavings,  or  by  heat- 
ing a mixture  of  nitrate  of  potassa  and  sulphuric  acid  in  an  iron  or  porcelain  dish;  or  with  chlor- 
ine gas  (of  little  use  iu  cholera),  by  mixing  a quart  of  muriatic  acid  and  a pint  of  water,  and 
pouring  it  upon  a pound  of  finely  powdered  black  oxide  of  manganese,  or  by  any  other  methods 
of  evolving  this  gas.  Sulphurous  acid  gas  is  the  most  effectual  and  the  most  easily  applied  of  all 
the  agents  of  fumigation.  Before  fumigation  begins  let  all  chimneys  and  windows  be  closed; 
as  soon  as  begun  let  the  person  on  duty  withdraw  from  the  place,  close  all  the  doors,  and  keep 
them  closed  for  twelve  hours.  Then  open  every  window,  door  and  aperture,  and  keep  open  for 
successive  days  and  nights.  There  is  no  substitute  for  cleanliness  and  ventilation.  To  protect 
from  cholera,  attend  to  these  sanitary  duties,  and  also  destroy,  by  chemical  agents,  the  choleraic 
discharges. 

Quantity  and  Kind  of  Disinfectants  which  are  Required  for  Common  Use. — Recent  reports 
from  Professors  Pettenkofer  and  Wunderlich,  from  Dr.  Muhling,  of  Constantinople,  and  the  espe- 
cially excellent  ones  by  Dr.  Angus  Smith,  Hr.  Crookes  and  Professor  Rolliston,  as  well  as  our  own 
experience,  fully  confirm  the  confidence  we  have  placed  in  the  crude  sulphate  of  iron  and  car- 
bolic acid,  for  use  upon  the  surfaces  or  in  the  vessels  that  receive  the  cholera  excrement.  There 
are  many  other  chemical  agents  that  can  control  or  destroy  the  infective  property  of  the  excre- 
mental  matters,  but  these  are  the  most  available,  because,  at  the  same  time,  the  cheapest  and  most 
effectual. 

Let  it  be  borne  in  mind  by  all  sanitary  authorities  that  the  object  of  all  methods  of  cholera 
disinfection  is  to  destroy  or  to  hold  iu  perpetual  inactivity  the  excreta  of  the  sick  and  the  sources 
of  organic  putridity,  wherever  the  excrement  may  bo  cast  away.  The  saturated  solutions  of  sul- 
phate of  iron  and  carbolic  acid,  when  employed  jointly,  or  in  the  order  here  mentioned,  most 
■ certainly  accomplish  such  disinfection  when  properly  applied.  They  are  our  best  and  cheapest 
antiseptics. 

Boiling  and  high  steam  heat  will  most  speedily  and  effectually  disinfect  foul  clothing.  The 
floating  hospital  has  testified  to  this  fact  these  eight  years  past.  But  all  kinds  of  clothing  and 
surfaces  soiled  by  the  cholera  fluids  require  antiseptic  care  until  they  are  washed.  In  the  English 
■■  towns,  carbolic  acid  is  employed  for  this  purpose,  although  it  is  apt  to  destroy  the  fabrics,  as  it 
f is  but  sparingly  soluble  (about  one  per  cent,  only,  in  water). 

The  permanganate  of  potash  is,  both  theoretically  and  practically,  the  best  and  most  econom- 
I ical,  for  it  does  not  impair  the  fabrics  it  touches,  if  properly  diluted,  while,  at  the  same  time,  it 
gives  a color  test  of  its  effective  presence. 

Chloride  of  lime  and  chlorinated  soda  solutions  will  unquestionably  hold  tho  cholera  poison  in 
' check  for  a time,  but  we  have  seen  very  decided  proofs  that  their  disinfecting  power  is  transient 
and  unreliable.” — “Annual  Report  of  tho  Metropolitan  Board  of  Health,”  1866. 

Tho  objects  of  the  preceding  directions,  as  propounded  by  Dr.  Elisha  Harris,  and  other  Ameri- 
can and  European  sanitarians,  were: — 

1.  To  destroy  or  to  neutralize  the  offensive  gases  and  products  of  putrefaction. 

2.  To  prevent  fermentation  and  putrefaction. 

To  destroy  all  infection  and  infectivo  processes  in  tho  specific  contagions  and  infections. 


380 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


It  was  not  until  the  results  of  the  more  exact  and  defined  experience  and  researches,  in  the 
epidemics  of  1854,  1859  and  1865,  in  Europe,  had  been  analyzed  and  compared,  that  The  conclu- 
sion was  reached — 

That  the  diarrhoeal  excreta  of  the  sick  when  impregnating  the  soil,  the  drinking  water,  or 
any  kind  of  decomposing  matter,  especially  that  of  privies,  cesspools,  sewers,  drains,  and  the 
ground  about  dwelling  houses,  constitute  the  positive,  the  chief,  and,  for  aught  that  is  yet  known, 
the  only  means  of  propagating  and  spreading  Asiatic  cholera. 

This  proposition  being  granted,  the  conclusion  is  reached:  That  the  cholera  germs  or  infec- 
tion, by  whatever  means  they  chance  to  be  introduced  into  any  town  or  city,  will  be  epidemically 
propagated  only  where  and  when  certain  conditions  of  putrescence  in  the  earth,  the  atmosphere, 
or  the  potable  water,  are  present;  that  where  any  two  or  more  of  these  unhealthful  circumstances 
are  present,  the  certainty  and  severity  of  the  epidemic  will  be  greatly  increased,  unless  the  disin- 
fecting power  of  acid  antiseptics  is  brought  to  bear  at  every  point  of  infectious  exposuro;  and, 
finally,  the  co-existence  and  co-operation  of  surface  moisture  of  the  ground — technically,  in  the 
words  of  Pettenkofer,  the  ground-water — is  the  most  constant  and  essential  of  all  the  physical 
agencies  that  promote  the  propagation  of  cholera,  after  the  germs  of  infection  have  been  intro- 
duced. 

The  view  has  long  been  held  that  the  cause  of  cholera  and  zymotic  diseases  was  in  some 
way  dependent  upon  cell  germs  and  cell  growth,  more  or  less  like  certain  ferments;  and  ever 
since  1838  the  best  microscopical  students,  particularly  those  who  were  familiar  with  the  minutest 
forms  of  vegetable  and  animal  parasites,  have  sought  for  the  existence  of  some  minute  kind  of 
eryptogamic  cell  growth  or  fungus  parasite  that  might  turn  out  to  be  found  exclusively  in  the 
rice-water  excrement  of  the  cholera  sick. 

During  the  year  1866,  several  of  the  ablest  mieroseopists  in  Europe,  independently  of  each 
other,  reached  the  same  results,  which  may  be  thus  expressed : — 

In  the  rice-water  excrement  of  cholera  patients,  and  within  the  intestinal  canal  of  such 
persons,  also  in  the  water  and  soil  that  have  been  in  any  manner  made  to  receive  or  imbibe  the 
rice-water  excrement,  is  discovered  a peculiar  cell  growth  or  fungus  cyst,  that  in  most  respects 
resembles,  in  its  developed  state,  the  fungus  Penicillium  and  the  Oidium,  that  are  so  well  known 
in  connection  with  certain  blighting  diseases  of  cereals,  as  well  as  with  the  diphtheritic  and  other 
diseases  of  the  human  body.  This  new  and  peculiar  species  of  fungus  cell,  called  by  Professors 
Thome  and  Klobe  cylindro-taenium,  or  zoo-glua,  and  considered  by  Professors  Hallier  and  Simon 
as  an  exotic  member  of  the  family  to  which  the  urocystic  and  oidium  blights  of  cereal  grain 
belong,  is  distinguished  for  its  rapidity  of  development,  strange  forms  of  growth,  and  its  fatal 
destruction  o-f  the  epithelial  tissue  of  the  intestine.  Professor  Hallier  has  proved  that  from  the 
Penicillium  stage  of  development  of  the  cholera  fungus  it  would  grow  luxuriantly  in  the  rice- 
plant,  which  is  a native  of  India.  As  described  by  Professor  Ernest  Hallier,  of  Jena,  this 
cholera  fungus  cell  growth  is  a Penicillium-bearing  one,  which  is  known  to  be  a native  of  India 
only,  and  as  having  the  following  peculiarities : — 

1.  As  shown  in  all  his  experiments  its  life  power  of  further  propagation  or  growth  is 
instantly  destroyed  by  an  acid  condition  of  the  fluid  or  soil  in  which  their  growth  was  observed. 

2.  The  presence  of  an  abundance  of  nitrogenous  matter,  and  the  absence  of  acids  in  the  soil, 
the  substance  or  the  fluid  in  which  the  propagation  and  development  of  the  cholera  fungus  was 
being  observed,  experimentally,  was  proved  to  be  an  essential  condition  for  such  propagation  and 
growth. 

3.  When  the  fungus  cells,  in  the  course  of  their  development  upon  a piece  of  intestinal  mem- 
brane (in  a bottle)  reached  a certain  stage,  they  rapidly  increased,  and  the  epithelium  as  rapidly 
wasted  away. 

It  is  evident,  therefore,  that  the  investigations  of  1865,  and  1866,  and  the  sanitary  measures 
instituted  in  Europe  and  America,  constituted  a new  and  important  era  in  sanitary  and  medical 
science  ; and  in  the  latter  country,  the  first  and  greatest  advances  were  made  by  the  Board  of 
Health  of  New  York,  and  especially  by  its  Registrar  of  Vital  Statistics,  Dr.  Elisha  Harris. 

In  the  Gardener’s  Chronicle,  November  9th,  1867,  a description  is  given,  by  tbe  Hon.  W.  Hope, 
of  experiments  made  in  diseased  cattle  at  his  farm,  near  Barking.  He  says  “ I thought  that 
while  there  was  life  thero  was  hope,  and  I determined  to  do  more  than  any  one  had  done  before. 
Where  one  man  had  used  a hundredweight  of  lime  I determined  to  uso  a ton,  and  whero  one  man 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  381 


had  used  a pint  of  carbolic  acid  I determined  to  use  a gallon.  . . The  dry  substance  I had  at 
hand  to  deal  with  in  large  quantities  was  lime.  This  I slaked  in  small  pyramids  in  the  centre  of 
the  sheds.  I also  laid  trains  of  it  outsido  tho  sheds,  underneath  the  ventilators,  and  then  slaked  it. 
I also  smothered  the  roads  and  paths  nt  different  points  in  layers  of  quicklime  three  or  four 
inches  deep,  so  that  every  man  and  animal  would  be  compelled  to  pass  it.  After  scouring  out  the 
sheds,  every  cow’s  tail  was  dipped  into  a bucket  of  carbolic  acid  and  water.  Their  heads  and 
noses  were  dabbed  over  with  it,  also  their  sides  and  flanks.  All  the  manure  and  litter  from  the 
cow’s  stall,  as  well  as  from  the  adjoining  ones,  was  taken  out  at  once  and  the  floor  thoroughly 
cleansed  and  saturated  with  carbolic  acid,  and,  on  the  suggestion  of  Professor  Brown,  I had  four 
days  previously  commenced  the  use  of  sawdust  saturated  with  carbolic  acid,  one  or  two  shovelsful 
of  which  were  placed  every  day  under  the  cow’s  head.  This  operation  was  also  repeated  in  every 
stall  and  the  cows  were  then  drenched  with  gruel  and  sulphite  of  soda.  Of  the  58  cows  in  shed 
D,  and  53  in  shed  E,  that  I took  the  entire  charge  of  and  treated  as  described,  I did  not  lose 
one.” 

The  rinderpest  having  broken  out  in  a herd  of  upward  of  260  cows,  in  its  virulent  form,  Mr. 
Hope  undertook  the  treatment  of  one-half  the  number  by  the  carbolic  acid  plan.  “ The  result 
was,”  says  Mr.  Hope,  “ that  while  every  single  animal  that  I did  not  take  charge  of  either  died  or 
was  slaughtered,  I succeeded  in  saving  every  single  animal  that  I did  take  charge  of.”* 

Dr.  Edmund  A.  Parkesf  has  expressed  his  conviction  that  carbolic  acid  deserves  the  foremost 
place  as  a means  of  limiting  the  spread  of  infectious  diseases.  Dr.  Parkes  inhaled,  for  the 
purpose  of  testing  their  morbid  effects,  the  exhalations  from  sewers.  The  first  effects  were  a nasal 
catarrh  and  an  irritation  of  the  mucous  membrane  of  the  throat;  hyper-salivation  followed,  and 
subsequently,  after  an  interval  of  30  to  50  minutes,  nausea.  In  a few  hours  occurred  chilliness, 
headache  and  fever,  lasting  from  20  to  24  hours.  None  of  these  effects  were  observed  when 
the  sewage  matters  had  been  previously  treated  with  a sufficiency  of  carbolic  acid. 

Dr.  Wm.  Budd,  of  Bristol,  has  stated  that  by  the  employment  of  disinfectant  agents,  “the 
contagion  of  scarlet  fever,  of  whooping  cough,  of  diphtheria,  and  many  others  of  the  same  family 
may  be  in  great  degree,  if  not  wholly,  disarmed.”  There  is  also,  he  says,  every  reason  to  believe 
that  the  contagion  of  typhus  may  be  thus  limited. 

We  have  thus  brought  the  history  of  disinfectants  down  to  the  period  in  which  they  were  first 
used  systematically  for  the  arrest  of  yellow  fever  by  Dr.  S.  A.  Smith,  President  of  the  Board  of 
Health  of  New  Orleans,  during  the  yellow  fever  epidemic  of  1867,  during  which  3107  inhabitants 
of  this  city  fell  victims  to  this  disease. 

The  result  of  these  efforts  to  limit  and  control  yellow  fever  by  means  of  sanitary  measures  and 
certain  disinfectants,  as  carbolic  acid  and  sulphurous  acid,  will  receive  careful  consideration  in 
the  division  of  our  researches  especially  devoted  to  this  subject. 

We  will  endeavor  to  examine,  in  the  next  place,  those  facts  which  illustrate  the  chemical 
properties  and  mode  of  action  of  carbolic  acid  as  an  antiseptic  and  disinfectant. 

Chemical  Properties  and  Relations  of  Carbolic  Acid. — Phenic,  or  carbolic  acid,  phenyl 
hydrate,  phenol  (CeHeO,  or  H.C6II60),  the  most  abundant  acid  product  of  the  distillation  of  pit- 
coal,  and  produced  also  by  the  distillation  of  the  salicylates,  of  the  alkalies,  and  of  the  earths,  and 
found  also  among  the  products  of  the  distillation  of  gum  benzoin  and  of  the  resin  of  the 
Xanthorrhoea  hastilis,  is  classed  under  the  secondary  aromatic  alcohols,  and  in  this  connection  is 
| termed  phenol;  and  while  giving  no  reaction  to  test  paper,  forms  with  bases  distinct  and  definite 
salts.  The  crystals  of  phenic  acid  melt  at  a temperature  of  about  105.8°  F.  (41°  C.),  and  the  liquid 
enters  into  ebullition  between  369°  and  370°  F.  Phenic  acid  requires  25  to  30  parts  of  water  for 
solution,  but  is  dissolved  by  alcohol,  ether  and  concentrated  acetic  acid  in  all  proportions.  When 
agitated  with  solution  of  caustic  potash  of  sp.  gr.  1060,  the  carbolic  acid  mixes  freely  with  the 
alkaline  ley,  but  a large  portion  of  the  acid  separates  on  dilution.  Phenic  acid  has  a burning 
taste  and  an  odor  of  wood  smoke,  resembling  that  of  creasote;  its  vapor  strongly  attacks  the  skin 
of  the  lips  and  gums,  and  it  possesses  antiseptic  properties  similar  to  those  of  creasote,  and 
indeed,  much  of  the  commercial  creasote  consists  solely  of  phenic  acid.  Phenic  acid,  when 
heated  with  ammonia  in  a sealed  tube,  becomes  partially  converted  into  water  and  aniline.  Tho 
acid  combines  with  potash,  and  forms  with  it  a crystalline  compound,  though  it  may  be  distilled, 


* Chemical  News,  October  21st,  1870,  p.  196. 


f Lancet , November  21st,  1868. 


382 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


unchanged,  from  caustic  potash,  or  from  quicklime,  or  caustic  baryta  in  excess.  Phenates  of  these 
bases  may  be  obtained,  but  they  are  easily  decomposed  ; with  oxide  of  lead  an  insoluble  compound 
may  be  obtained.  It  combines  with  sulphuric  acid,  with  which  it  forms  a conjugated  acid. 

Phenic  acid  is  accompanied  in  coal  tar  by  other  homologous  bodies  which  greatly  resemble  it. 
By  subjecting  commercial  coal  tar  creasote  to  fractional  distillation,  Williamson  obtained  a liquid 
which  boils  at  397.4°  F.,  and  which  is  nearly  insoluble  in  solution  of  ammonia. 

Kresylic  acid,  kresol,  or  methyl-phenol,  is  soluble  in  oil  of  vitriol,  producing  a violet  color 
and  forming  a compound  acid.  This  substance  is  metameric  with  anisol,  and  with  benzyl  alco- 
hol; it  is  the  phenol  of  the  toluric  series.  When  treated  with  fuming  nitric  acid  it  is  oxidized 
with  almost  explosive  violence,  and  trinitro-kresylic  acid,  homologous  with  carbazotic  acid,  is 
produced.  A third  homologue,  xylyl-phenol,  also  occurs  in  coal  tar  in  small  proportions.  It  is 
probably  dymethyl-phenol,  but  it  has  not  been  accurately  investigated.  Isomeric  with  this  body 
is  phlorol,  obtained  by  distilling  calcic  phlorotate  with  lime.  It  is  a colorless,  highly  refractive 
oil,  with  a burning  taste,  and  an  odor  recalling  that  of  carbolic  acid.  Thymol  also,  according  to 
Kekule,  is  a homologue  of  carbolic  acid ; but  this  appears  to  be  doubtful. 

Phenic  acid  may  be  caused  to  furnish  ethers  with  alcohol  radicles  by  a process  of  double 
decomposition,  which  consists  in  distilling  potassic  methylsulphate,  ethylsulphate,  or  anlylsulphate 
with  potassic  phenate.  These  ethers  may  likewise  be  procured  by  heating  potassic  phenate  with 
the  iodide  of  methyl,  of  ethyl,  or  of  amyl;  they  are  also  produced  by  the  distillation  of  the  sali- 
cylic ethers  with  caustic  baryta. 

Phenic  acid  gives  rise,  by  substitution,  to  an  unusual  number  of  acid  compounds,  formed  upon 
the  type  of  phenic  acid  itself.  All  these  acids  are  monobasic  and  form  definite  salts,  many  of 
which  crystallize  very  beautifully. 

A mixture  of  potassic  chlorate  and  hydrochloric  acid  converts  phenic  acid  into  trichloro- 
phenic  acid,  and  by  prolonged  action  chloronil  is  produced. 

Oil  of  vitriol  dissolves  phenic  acid  without  change  of  color,  and  produces  a compound  mono- 
basic acid,  termed  sulphophenic  acid ; it  forms  with  barium  a soluble  salt,  which  crystallizes  in 
tufts  of  needles.  If  phenic  acid  be  allowed  to  fall,  drop  by  drop,  into  fuming  nitric  acid,  it  is 
attacked  with  great  violence ; each  drop  produces  a hissing  like  that  which  accompanies  the 
quenching  of  a hot  iron;  and  upon  boiling  the  mixture  carbazotic  (trinitrophenic)  acid  is 
obtained.  If  the  acid  be  more  dilute,  nitrophenic  acid,  or  dinitrophenic  acid,  is  produced.  Both 
these  acids  may  readily  be  obtained  in  crystals.  Most  of  these  salts  crystallize  with  facility ; they 
greatly  resemble  the  carbazotates. 

Antiseptic  Action  of  Carbolic  Acid  on  Vegetable  and  Animal  Substances.  Poisonous  Effects 
of  Carbolic  Acid. — The  aqueous  solution  of  carbolic  acid  coagulates  albumen;  it  unites  with  cer- 
tain animal  substances  and  preserves  them  from  decomposition,  even  removing  the  fetid  odor 
from  meat  and  other  substances  already  in  a state  of  decomposition.  Fish  and  leeches  die  when 
immersed  in  the  aqueous  solution,  and  their  bodies  subsequently  dry  up  on  exposure  to  the  air, 
without  putrefying. 

M.  Mehu*  and  Dr.  Meymott  Tidy  have  recommended  carbolic  acid,  dissolved  in  acetic  acid, 
as  a delicate  test  for  albumen  in  the  urine.  The  process,  however,  does  not  appear  to  bo  more 
delicate,  or  as  reliable,  as  the  long-established  test  of  nitric  acid  and  heat. 

We  have  seen  that  carbolic  acid  enters  into  union  with  inorganic  bases,  forming  definite  com- 
pounds, and  that  it  may  be  readily  displaced  from  its  combinations.  M.  Romeif  considers  the 
compounds  merely  juxtapositions  of  the  molecules,  each  constituent  preserving  unchanged  its 
inherent  character. 

It  is  important  to  know  whether,  in  the  case  of  the  organic  bodies  with  which  the  agent  may 
come  in  contact,  it  may  form  compounds  which  may  modify  the  original  properties. 

This  question  has  been  carefully  considered  by  Dr.  Arthur  Ernest  Sansom,  in  his  elaborate 
and  valuable  treatise  on  “The  Antiseptic  System. ”{ 

While  carbolic  acid  has  a certain  affinity  for  albumen,  Dr.  Sansom  has  shown  that  the  pres- 
ence of  this  substance,  or  of  potash,  in  small  quantities,  does  not  impair  its  power  of  arresting 
fermentation. 


* Journal  de  Pharmacie  et  de  C/iimie,  February,  18G9. 
f Bulletin  de  la  Socitti  Chimique , February,  18G9. 


I Page  17. 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  383 


Dr.  Sansom  has  shown  that  a mixture  of  glycerine  and  carbolic  acid  acts  upon  the  sensitive  sur- 
face of  the  skin  in  a far  less  energetic  manner  than  the  aqueous  solution  ; the  presence  of  glyce- 
rine impairs  in  a very  obvious  manner  the  power  to  arrest  saccharine  fermentation;  carbolic 
acid  appears  to  unite  chemically  with  glycerine.  In  like  manner,  when  united  with  olive  oil,  the 
energy  of  its  action  on  the  skin  is  diminished,  and  its  power  of  arresting  fermentation  and  putre- 
faction is  impaired.  A five  per  cent,  solution  of  carbolic  acid  in  olive  oil  fails  to  prevent  the 
putrefaction  of  flesh,  though  a one  per  cent,  watery  solution  will  entirely  prevent  such  decompo- 
sition ; it  appears,  therefore,  to  enter  into  combination  with  fatty  matters.  Alcohol  also  lessens  its 
power  over  fermentation. 

Dr.  Sansom  concludes  that  these  considerations  are  sufficient  to  show  that  carbolic  acid  readily 
enters  into  combination  with  the  organic  bodies  with  which  it  comes  into  relation,  and  that 
these  are  prone  to  mutual  variations,  and  that  then  the  original  properties  of  the  agent  become 
modified. 

The  chief  value  of  carbolic  acid,  and  the  compounds  associated  with  it,  is  its  property  of 
destroying  vegetable  and  animal  organisms,  and  its  antiseptic  property  of  preventing  fermenta- 
tion and  putrefaction. 

Carbolic  acid  not  only  prevents  fermentation,  hut  it  also  arrests  it,  when  it  has  once  com- 
menced ; although,  on  the  other  hand,  it  does  not  prevent  the  conversion  of  starch  into  dextrine, 
or  the  fermentation  of  the  essential  oil  of  almonds  when  amygdalin  is  mixed  with  synaptose. 

Dr.  Sansom  has  shown  that  the  following  quantities  of  various  agents  will  wholly  arrest  the 
fermentation  of  twenty-five  grains  of  cane  sugar:  Perchloride  of  mercury,  grain  0.03;  hydrated 
sulphuric  acid,  grain,  0.10 ; carbolic  acid,  grains  2.00 ; perchloride  of  iron,  grains  3.90 ; car- 
bonate of  potash,  grains  4.00 ; sulphite  of  soda,  grains  5.00 ; sulphocarbolate  of  soda,  grains,  20.00. 

Mr.  Crooks,  in  his  Report  to  the  Cattle  Plague  Commissioners,  related  an  experiment  which 
tended  to  show  that  the  action  of  carbolic  acid  in  restraining  fermentation  was  directed  upon  the 
yeast,  and  that  the  power  of  yeast  to  induce  fermentation  was  wholly  destroyed  by  feeble  solu- 
tions of  carbolic  acid.  Mr.  Crooks  washed  yeast  with  a one  per  cent,  aqueous  solution  of  carbolic 
acid,  and  then  washed  away  with  water,  as  far  as  possible,  the  carbolic  acid.  The  experiment 
several  times  repeated  always  showed  that  the  power  of  exciting  fermentation  was  wholly 
destroyed.  This  conclusion,  however,  was  contested  by  Pettenkofer,  who  says  that  though  car- 
bolic acid  preserves  ferment  cells  in  an  inert  state,  yet  when  the  volatile  acid  has  become  dissi- 
pated these  resume  their  activity.  Dr.  Sansom,  who  submitted  this  question  to  experimental 
demonstration,  concludes  that : — 

“Without  as  yet  hazarding  any  hypothesis  as  to  the  nature  of  fermentation,  our  data  show 
that  the  yeast  is  the  element  which  is  acted  upon,  and  there  is  no  sign  that  this  is  chemical!// 
altered.” 

The  action  upon  the  yeast  would  appear  to  be  not  temporary,  but  permanent.  Dr.  Angus 
Smith*  remarks  upon  the  same  subject,  that  his  experiments  led  him  to  believe  that  Pettenkofer 
must  have  used  very  weak  acid. 

Abundant  experimentation  has  proved  that  carbolic  acid  prevents  the  putrefaction  of  organic 
substances ; that  in  small  quantities  it  prevents  the  germination  of  the  spores  of  the  yeast  plant  and 
various  seeds,  as  lentils,  kidney  beans,  barley  and  oats;  that  an  infinitesimal  quantity  instantly 
kills  bacteria,  vibrios,  spirilla,  amoebae,  monads,  eugliniae,  paramaciae,  rotifera,  and  vorticellae; 
that  it  destroys  ascarides,  the  ova  of  ants,  earwigs,  and  butterflies;  that  it  kills  Jumbrici,  cater- 
pillars, bulles,  crickets,  fleas,  moths,  fish,  frogs,  leeches,  birds  and  animals. 

The  multitude  of  observations  which  have  been  made,  and  the  experience  of  every  day,  leave 
no  room  to  doubt  that  carbolic  acid  has  a great  power  in  arresting  both  fermentation  and  putre- 
faction ; and,  at  the  same  time,  accumulated  observations  by  Crooks,  Roberts,  Angus  Smith, 
Dougal,  Sansom,  and  many  others,  show  that  it  does  not  exert  any  appreciable  influence  on 
: oxidation.  Oxidation  of  potassium,  sodium,  iron,  copper,  lead,  manganese  and  phosphorus  have 

been  observed  to  take  place  as  readily  in  aerial  or  aqueous  atmospheres,  impregnated  with  car- 
bolic acid,  as  in  cases  when  the  latter  is  entirely  absent. 

That  carbolic  acid  has  an  action  over  and  above  its  faculty  of  coagulating  albumen,  and  does 
not  prevent  or  arrest  fermentation  or  putrefaction  solely  in  virtue  of  its  power  of  coagulating 


*“  Disinfectants  and  Disinfection,’’  p.  63. 


384 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


albumen,  is  shown  conclusively  by  the  fact  that  if  a solution  of  albumen  be  precipitated  in  one 
case  by  heat  or  by  an  ordinary  chemical  agent,  and  in  the  other  by  a solution  of  carbolic  acid, 
the  resultant  precipitate,  if  kept  in  contact  with  the  air,  will  in  the  first  case  be  decomposed  in  the 
ordinary  manner,  while  that  precipitated  by  the  carbolic  acid  entirely  resists  putrefactive  change. 

The  conclusion  has  been  drawn  from  tbc  preceding  facts,  that  carbolic  acid  does  not  operate  in 
an}'  manner  obviously  chemical,  but  that  it  has  a manifest  effect  upon  vitality , and  that  it  has  the 
power  of  killing,  in  feeble  doses  and  in  a marked  manner,  the  lower  manifestations  of  animal  and 
vegetable  life,  which  are  intimately  associated  with  the  processes  of  fermentation  and  putre- 
faction. 

When  carbolic  acid  is  added  to  a solution  susceptible  of  putrefaction,  and  before  the  com- 
mencement of  any  putrefactive  decomposition,  no  organisms  are  developed  ; and  when  added  to  a 
putrefying  solution,  all  the  infusoria  present  in  that  solution  instantly  die,  and  the  cessation  of 
putrefactive  change  is  coincident  with  their  death ; there  is,  therefore,  a direct  connection 
between  the  manifestation  of  living  things  and  the  occurrence  and  progress  of  putrefaction,  and 
it  is  in  virtue  of  its  power  of  suppressing  vitality  that  carbolic  acid  acts  as  an  antiseptic. 

It  would  be  foreign  to  our  purpose  to  examine  the  testimony  accumulated  from  the  time  of  the 
experiments  of  Redi,  in  Florence  in  1638,  to  the  present  moment,  including  the  observations  of 
Needham,  Bonnet,  Spallanzani,  Lamarck,  Cabanis,  Bory,  St.  Vincent,  Bremser,  Tiedemann,  I. 
Muller,  Dumas,  Dujardin,  Burdach,  Gay  Lussac,  Schwann,  Schroder,  Dusch,  Pouchet,  Pasteur, 
Hallier  of  Jena,  Bastian,  Huxley,  Owen  and  others,  which  have  led  to  the  promulgation  of  the 
two  rival  theories  of  the  heterogenists  and  pan-spermatists  with  regard  to  putrefaction. 

According  to  the  heterogenists,  “putrefaction  is  a chemical  change  which  moist  organic  mat- 
ter is  prone  to  undergo  under  certain  influences.  It  is  a slow  process  of  oxidation.  Its  primum 
movens  is  an  albuminous  body  (the  putrescible  matter  itself),  whose  particles  are  in  a condition  of 
motion,  which  motion  is  capable  of  communicating  by  catalysis  to  contiguous  organic  matter. 
The  initial  changes  are  chemical  changes  ; these  chemical  changes  place  the  organic  matter  in 
such  conditions  as  favor  its  transformation,  under  ordinary  physical  forces,  into  organisms  pos- 
sessing vitality.  Hence,  these  arise  de  novo  from  the  dead  material ; their  occurrence  is  non- 
essential  to  the  process ; either  they  are  entirely  adventitious,  or  they  are  only  intermediary 
means  of  transformation.” 

According  to  the  theory  held  by  the  Pan-spermatists,  “ Putrefaction  is  a transformation  of 
organic  matter  entirely  effected  by  the  influence  of  vitally  endowed  organisms.  The  chemical 
changes  in  putrefaction  are  the  sum  of  the  products  and  the  acts  of  living  beings.  The  first 
cause  is  a multitude  of  minute  particles  of  vitally  endowed  matter  derived  from  the  pre-existing 
living  beings,  contained  in  the  air,  permeating  all  substances  which  air  itself  permeates,  wafted 
from  place  to  place,  finding  in  the  putrescible  fluid  a suitable  soil  or  pabulum,  in  which,  in  various 
forms,  to  live,  grow  and  multiply.  The  universally  present  living  particles  are  essential  to  the 
process  of  putrefaction,  and  when  they  are  destroyed,  putrefaction  cannot  take  place.” 

The  force  of  the  evidence  with  reference  to  carbolic  acid  sustains  the  theory  of  fermentation 
and  putrefaction  held  by  the  Pan-spermatists,  and  it  owes  its  antiseptic  power  to  its  poisonous 
effects  upon  those  organisms  which  are  so  uniformly  distributed  upon  the  surface  of  the  earth, 
and  throughout  the  atmosphere,  upon  which  the  processes  of  fermentation  and  putrefaction 
depend. 

When  we  endeavor  to  apply  the  preceding  facts  to  the  explanation  of  the  mode  in  which 
certain  chemical  compounds,  as  sulphurous  acid,  chlorine  and  carbolic  acid,  arrest  .contagious 
and  infectious  diseases,  the  following  facts  should  be  considered: — 

1.  All  disinfectants  and  antiseptics  possess  the  power  of  arresting  fermentation  ami  putrefac- 
tion, and  consequently  alter  the  chemical  and  physical  constitution  and  properties,  or  embalm 
and  preserve  from  further  change  organic  substances. 

2.  All  disinfectants  and  antiseptics  are  destructive  of  those  forms  of  plants  and  animals  upon 
which  fermentation  and  putrefaction  depend. 

3.  Carbolic  acid  especially  arrests  the  chemical  changes  of  germinal  matter,  and  of  individual 
cells,  and  of  the  lower  organisms;  it  is  destructive  of  life. 

4.  Diseases  maybe  caused  by  chemical  and  physical  changes  of  the  atmosphere:  by  the 
presence  of  certain  gases,  some  of  which  may  bo  evolved  from  the  bowels  of  the  earth  and  others 
from  decomposition  and  putrefaction  of  vegetable  and  animal  matters  upon  the  surface  of  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  385 


earth;  by  alternations  of  heat,  cold  and  moisture;  by  variations  in  the  amount  and  mode  of 
action  of  the  terrestrial  electricity;  by  changes  of  diet,  habits  of  life  and  occupation;  by  foul 
gases,  volatile  animal  matters  and  putrefying  secretions  and  excretions,  resulting  from  crowding 
in  ill-ventilated  and  filthy  ships,  camps,  hospitals  and  houses;  by  tangible  organic  poisons  propa- 
gated in  and  through  the  human  system,  as  of  syphilis  and  smallpox;  by  vegetable  or  animal 
matters,  or  living  germs,  which  may  assume  new  forms  and  develop  now  products  in  accordance 
with  the  soil  in  which  they  are  grown,  extremely  minute  living  organisms,  having  the  character- 
istic endowments  of  vegetable  growths,  analogous  to  the  minute  particles  of  vegetable  protoplasm 
whose  function  it  is  to  disintegrate  and  convert  complex  organic  products,  owing  their  specific 
properties  in  special  diseases,  not  to  any  botanical  characters,  but  to  the  characters  implanted  in  them 
from  the  soil  in  which  they  sprang  from  innocuous  parents,  and  from  which  they  are  transmitted, 
and  this  soil,  except  in  the  case  of  their  earliest  origin,  being  the  fluids  of  the  animal  body  ; by 
i minute  living  organisms,  fungi  and  animalculae,  possessing  inherent  poisonous  properties,  and 
i capable  of  inducing  specific  diseases  according  to  their  species  and  genera,  and  being  dependent 
for  their  existence  and  propagation  upon  special  climatic  conditions  of  heat,  moisture  and  animal 
: and  vegetable  matters. 

5.  The  ancient  belief  that  decomposing  animal  and  vegetable  substances  produce  disease, 
i and  are  ultimately  connected  with  contagion  and  infection,  has  been  revived  in  modern  times; 

1 and  it  might  be  said  that  up  to  the  middle  of  the  present  century  this  crude  and  gross  result  of 
ri  sanitary  investigation  summed  up  all  that  had  been  done  by  boards  of  health  and  sanitary  com- 
■ missions;  while  the  decomposition  of  organized  beings  after  death,  and  of  organic  matters 
i generally,  both  vegetable  and  animal,  may  produce  gases  and  vapors  that  are  injurious  to 
[i  health,  and  which  may  favor  the  spread  of  certain  diseases,  as  cholera,  plague  and  yellow  fever, 
i they  are  incapable  of  originating  these  diseases.  While  it  is  difficult  to  determine  the  place  and 

mode  of  origin  of  these  diseases  in  the  warm  climates  where  they  appear  to  bo  indigenous,  when 
• imported  into  more  temperate  latitudes  they  prevail  with  most  destructive  effects  in  crowded  and 
d filthy  localities  and  habitations,  where  decomposing  animal  and  vegetable  matters  pollute  the  air. 
‘ The  fostering  effect  of  decomposing  organic  matter  on  disease  has  been  likened  to  the  rapid 
r growth  of  seeds  planted  in  the  rich,  fertile  soil  of  decomposing  matter,  or  to  the  action  of  the 
yeast  plant,  “as  if  the  putrid  matter  itself  took  the  disease  and  transformed  it  to  the  living.” 

6.  When  the  effort  is  made  to  determine  the  nature  of  the  substance  which  forms  the  seed  or 
i germ  of  the  disease,  not  merely  the  decomposing  substance,  but  the  resulting  gases,  and  the  various 
a organisms  existing  in  the  air  and  water  and  on  the  surface  of  the  earth,  demand  investigation. 

If  the  labors  of  chemists  who  have  examined  the  gaseous  compounds  resulting  from  thedecompo- 
i sition  of  organic  substances,  such  as  sulphureted  hydrogen,  sulphuret  of  ammonium,  carbonic 
acid,  nitrogen,  carbonic  oxide,  carbureted  hydrogen,  phosphoreted  hydrogen,  ammonia,  acetic 
acid  and  alcohol,  be  carefully  examined,  it  will  be  foun  t that  while  it  has  been  established  that 
i certain  of  these  gases,  as  sulphureted  hydrogen,  are  destructive  of  life  when  concentrated,  no 
4 combination  of  these  gases  in  the  laboratory  and  in  experiments  has  ever  produced  a contagious. 
i infectious  or  specific  disease,  capable  of  propagation.  While  these  gases,  which  are  easily  diffused 
into  air,  and  are  more  or  less  soluble  in  water  are,  in  certain  proportions,  injurious  to  human 
^ beings,  their  action  even  in  the  most  rapid  decompositions  on  the  surface  of  the  earth  are  wholly 
't  different  from  those  of  the  organic  contagious  matters;  and  in  like  manner  wo  must  conceive  that 
1 their  action  is  different  from  those  vapors  in  which  may  be  concentrated  the  organic  impurities 
I of  the  atmosphere,  or  of  putrid  decomposing  substances  and  organized  bodies,  animalculae, 
fungi,  etc.,  mechanically  suspended  in  the  atmosphere. 

7.  However  disease  may  be  produced,  by  specific,  organized  germs,  or  contagious  combinations 
j of  germinal  organic  matter,  originally  developed  in  the  human  constitution,  and  propagatod 
1 through  succeeding  generations ; or  by  well  known  gases,  as  sulphureted  hydrogen,  phosphoreted 
ihydrogcn,  carbureted  hydrogen,  or  hydrocyanic  acid,  easily  diffused  in  the  air;  or  by  heavy 
•ivapors,  enclosing  the  products  of  the  decomposition  of  marshes;  or  by  putrid  decomposing  sub- 

Mistances,  mechanically  diffused;  or  by  organized  living  bodies,  acting  as  ferments,  or  as  carriors  of 
i the  contagious  putrid  matter:  the  true  remedy  is  disinfection,  chemical  alteration  of  the 
<«poisonous  matters,  arrest  of  all  life  action,  arrest  of  all  fermentation  and  putrefaction. 

By  means  of  such  agents  as  chlorine  and  sulphurous  acid  wo  destroy  sulphureted  hydrogen, 
•ilsulphurct  of  ammonium,  phosphoreted  hydrogen,  hydrocyanic  acid,  and  tho  various  combina- 
Vol.  IV— 25 


386 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


tions  of  hydrogen  and  carbon,  and  alter  the  constitution  of  those  organic  substances,  whether 
living  or  dead,  which  are  supposed  to  induce  disease;  and  in  like  manner  carbolic  acid  destroys 
living  germs,  arrests  fermentation  and  putrefaction,  and  thus  embalms  the  active  agents  in  the 
propagation  of  contagious  diseases. 

8.  A thorough  system  of  disinfection  should  embrace  — 

(а)  The  immediate  isolation  and  disinfection  of  the  first  case  or  cases  of  any  contagious 

disease. 

(б)  Free  ventilation  and  absolute  cleanliness. 

(c)  The  disinfection  of  surrounding  streets  and  houses  by  means  of  lime,  sulphurous  acid,  car- 

bolic acid,  sulphate  of  iron  and  corrosive  sublimate. 

( d ) Thorough  cleansing  and  disinfecting  of  the  bed  ling,  clothes,  rooms  and  premises  of  the 

various  outbreaks  of  yellow  fever,  cholera  and  other  zymotic  diseases,  by  means  of  such 
agents  as  chlorine,  sulphurous  acid,  permanganate  of  potash,  carbolic  acid  and  corrosive 
sublimate. 

These  notes  on  the  history  of  naval  hygiene  and  the  history  of  disinfection  and  disinfectants 
will,  without  doubt,  be  rendered  far  more  valuable  to  those  students  of  public  and  international 
hygiene  who  are  charged  with  the  responsible  duty  of  protecting  cities  and  States  from  the  rav- 
ages of  endemic,  epidemic  and  contagious  diseases,  if  the  practical  results  of  actual  experiments, 
during  a series  of  years,  in  a large  city  which  had  frequently  suffered  with  the  ravages  of  disease, 
be  carefully  and  methodically  unfolded. 

We  have  selected  for  the  illustration  of  the  practical  results  achieved  by  sanitarians  in  their 
experiments  with  disinfectants,  the  salient  facts  in  the  medical  and  hygienic  history  of  New 
Orleans,  from  the  close  of  the  American  civil  war,  in  1865,  up  to  the  present  time. 

No  city  within  the  bounds  of  the  United  States  of  America  has  suffered  more  repeatedly  or 
more  severely,  during  the  past  century,  from  yellow  fever,  than  New  Orleans,  as  will  be  seen  from 
the  following  record: — 


NUMBER  OP  DEATHS  IN  NEW  ORLEANS,  LOUISIANA,  DURING  THE  YEARS  SPECIFIED. 


Deaths  from 

Deaths  from 

Deaths  from 

Year. 

Yellow  Fever. 

Year. 

Yellow  Fever. 

Year. 

Yellow  Fever. 

1847, 

2306 

1860, 

15 

1872, 

39 

1848, 

80S 

1861, 

1873, 

226 

1849, 

769 

1862, 

2 

1874, 

11 

1850, 

107 

1863, 

2 

1875, 

61 

1851, 

17 

1864, 

6 

1876, 

42 

1852, 

456 

1865, 

1 

1877, 

1 

1853, 

7849 

1866, 

192 

1878, 

4056 

1854, 

2425 

1867, 

3107 

1879, 

' 19 

1855, 

2670 

1868, 

5 

1880, 

2 

1856, 

74 

1869, 

3 

1881, 

0 

1857, 

200 

1870, 

588 

1882, 

4 

1858, 

4845 

1871, 

54 

1883, 

1 

1859, 

91 

Deaths  from  yellow  fever  for  1847-1856,  17,4S1 ; 1857-1866  (ten  years),  5354;  1S67-1S76  (ten 
years),  4136;  1877-1883  (seven  years),  4082.  Total  (thirty-two  years),  1S57-1878,  inclusive, 
31,028;  total  deaths  (thirty-seven  years),  1847-1883,  31,051. 

Carbolic  acid  disinfection  was  first  proposed  and  practiced  in  New  Orleans  in  1866,  for  the 
arrest  of  contagious  and  infectious  diseases,  and  more  especially  for  the  arrest  of  yellow  fever; 
and  up  to  the  close  of  the  year  1879  it  was  used  in  the  most  lavish  manner  in  the  gutters  and  in 
the  streets,  and  in  and  around  all  infected  localities. 

During  eleven  years  in  which  carbolic  acid  was  used  upon  a larger  scalo  than  ever  beforo  in 
the  history  of  sanitary  science,  to  arrest  yellow  fever  by  the  creation  of  a special  atmosphere, 
namely,  1867-1878,  inclusive,  there  occurred  in  tho  city  of  New  Orleans  8193  deaths  from  yellow 
fever.  During  four  years,  1880,  1881,  1882  and  1S83,  in  which  not  one  gallon  of  carbolio  acid 
was  poured  in  tho  gutters  or  in  the  streets  in  tho  localities  where  yellow  fever  cases  were  reported, 
there  wore  but  six  deaths  attributed  to  yellow  fever.  The  subject  is  of  such  importance  to  public 
hygiene  that  wo  give  a full  outline  of  the  main  facts  of  tho  medical  history  of  New  Orleans, 
1866-1883. 


SECTION  XV — rUBLIC  AND  INTERNATIONAL  HYGIENE.  387 


HISTORY  OP  DISINFECTION  AND  OTHER  SANITARY  MEASURES  IN  NEW  ORLEANS,  LOUISIANA. 

Guyton  Morveau’s  method  of  fumigation  was  practiced  in  New  Orleans*  during  the  yellow 
fever  of  1S20,  by  Dr.  Forsyth,  with  beneficial  results,  in  the  family  of  a German,  usually  called 
“ Dutch  Joseph,”  who  had  contracted  yellow  fever  on  board  of  a Gerfnan  vessel  in  the  Mississippi 
river  infected  with  this  disease.  But  systematic  efforts  to  limit  and  eradicate  yellow  fever  were 
not  instituted  in  this  city  until  after  the  civil  war  of  1861-1865,  and  New  Orleans  had  existed  for 
a century  and  a half,  and  been  ravaged  by  no  less  than  a score  of  severe  epidemics,  before  the 
resources  of  chemistry  were  invoked  for  the  arrest  of  its  great  scourge. 

Dr.  E.  H.  Barton,  in  his  elaborate  report  on  the  sanitary  condition  of  New  Orleans,  in  1853, 
prophesied  that  “upon  the  broad  foundation  of  sanitary  measures,  we  can  erect  a monument  of 
public  health,  and  that  if  a beacon  light  be  erected  on  its  top,  and  kept  alive  by  proper  attention, 
this  city  will  be  second  to  none  in  this  first  of  earthly  blessings.” 

In  this  account  the  facts  shall  be  drawn  from  the  Official  Reports  of  the  Board  of  Health. 

Carbolic  acid  appears  to  have  been  first  used  for  the  “ arrest  of  yellow  fever,”  as  a “ disinfect- 
t ant,”  during  the  comparative  recent  and  memorable  epidemic  of  1867,  under  the  direction  of 
S.  A.  Smith,  m.d.,  President  of  the  Board  of  Health. 

In  the  preceding  year — 1866 — yellow  fever  had  prevailed  to  a limited  extent:  the  deaths  from 
! this  disease  neve"  rose  above  seven  per  day,  very  rarely  above  three.  Five  deaths  occurred  in 
,i  August,  56  in  September,  89  in  October,  31  in  November  and  four  in  December;  total,  185.  In 
! 1866,  the  mortality  was  almost  entirely  confined  to  persons  unacclimated,  and  recently  from  foreign 
i countries  or  Northern  States.  The  first  case  known  to  have  occurred  was  that  of  a Frenchman, 
who  died  with  black  vomit  at  the  Hotel  Dieu,  under  the  care  of  Dr.  Boyer,  on  the  10th  of  August. 
This  man  had  not  been  out  of  the  city  for  several  months,  save  to  hunt  and  fish.  On  the  Sunday 
) prior  to  his  attack  he  had  been  on  one  of  these  excursions,  and  complained,  on  his  return,  of  fatigue 
i and  weariness.  It  was  a month  before  any  other  fatal  case  was  reported.  The  Board  of  Health 
was  unable  to  trace  the  introduction  of  the  disease  through  the  quarantine. 

During  the  months  of  June,  July,  August,  September,  October,  November  and  December,  the 
deaths  caused  by  the  various  classes  of  fever  were  recorded  by  the  Board  of  Health  as  follows: 
Fever,  7;  bilious  fever,  59;  congestive  fever,  175;  continued  fever,  5;  gastric  fever,  2;  pernicious, 
132;  intermittent,  56:  brain,  27  ; nervous,  3;  Panama,  1 ; puerperal,  8;  remittent,  46;  scarlet,  17 : 
typhoid,  77 ; typhus,  12  ; yellow,  185 ; total  by  fevers,  712.  It  is  worthy  of  note  that  bilious,  con- 
i' gestive,  pernicious  and  intermittent  fevers  caused  422  deaths,  or  more  than  one-half  of  all  the 
- deaths  caused  by  fevers,  yellow  fever  included.  Of  the  185  deaths  by  yellow  fever,  93  occurred  in 
the  Charity  Hospital,  out  of  130  cases.  The  first  case  of  yellow  fever,  or  rather  the  first  case  that 
: terminated  fatally  with  black  vomit,  that  of  the  Frenchman,  was  employed  by  Mr.  Griswold,  on 
i:  Canal  street,  and  boarded  at  the  Orleans  Hotel,  on  Charles  street. 

On  the  14th  of  July,  a ease  on  Hercules  street,  attended  by  Dr.  Thierry,  died  with  Asiatic 
( cholera.  Dr.  Ball  afterward  reported  that  he  had  prescribed  for  other  suspicious  cases  in  the  same 
house  about  the  same  time.  The  Medical  Director,  Col.  McFarlin,  reported  that  on  the  22d  a 
recruit,  who  had  been  for  some  time  resident  in  New  Orleans,  and  belonging  to  a detachment  bil- 
leted at  Holmes’s  foundry,  near  the  New  Basin,  was  taken  with  cholera  and  died  in  a few  hours. 
Sixteen  cases  occurred  in  this  detachment  in  the  course  of  two  weeks,  five  of  whom  died.  The 
troops  were  removed  from  that  locality,  the  sick  men  sent  to  the  Sedgwick  Hospital,  immediate 
' steps  were  taken  to  disinfect  and  purify  the  quarters  and  baggage,  and  the  disease  soon  disap- 
i peared.  On  the  31st  of  July,  Dr.  Henderson  summoned  the  President  of  the  Board  of  Health, 
Dr.  S.  A.  Smith,  to  witness  the  case  of  a negro  woman  upon  Race  street;  by  the  1st  of  August, 
i cases  had  occurred  on  Race,  Robin  and  Felicity  streets,  also  among  the  soldiers  occupying  a cotton 
' press  on  Robin  street.  Dr.  Ball,  on  the  morning  of  the  1st  of  August,  invited  the  President  to 
see  a case  on  Liberty,  between  Thalia  and  Erato  streets.  It  was  that  of  a young  white  woman, 
t taken  at  2 A.M.,  hopeless  at  5.  After  seeing  it,  the  President  summoned  a meeting  of  the  Board 
of  Health,  and  gave  it  as  his  opinion  that  this  was  an  unmistakable  ease  of  cholera  asphyxia.  It 
was  not  until  the  3d  of  August  that  any  notice  was  given  of  its  introduction  into  the  Charity  Hos- 
pital, where  there  had  been  five  cases,  all  from  the  workhouse  near  the  Now  Basin,  and  the  first  was 

I - — 

*“An  Account  of  the  yellow  fever  as  it  prevailed  in  the  city  of  Now  York,  in  the  summer  and  autumn 
-1  of  1822.”  By  Peter  S.  Townsend,  M.D.  New  York,  1823,  p.  348. 


388 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


brought  in  on  the  1st  of  August.  On  the  3d,  the  first  case  was  reported  below  Canal  street,  and 
on  the  same  day  an  officer  of  the  Navy  Department  from  Algiers  reported  a number  of  cases  among 
his  employes;  on  the  4th,  Dr.  Milum  reported  it  in  Jefferson,  and  in  a short  time  the  disease  was 
diffused  throughout  the  city. 

Dr.  S.  A.  Smith,  President  of  the  Board  of  Health,  says:  “The  eases  of  the  disease  which 
occurred  presented  characters  of  excessive  malignity.  There  was  little  or  no  success  in  treating 
cases  in  collapse,  yet  the  weight  of  mortality  fell  almost  entirely  upon  colored  people  and  whites 
living  in  poor  conditions. 

“ How  to  account  for  the  almost  entire  exemption  of  the  population  living  in  good  circum- 
stances is  an  interesting  problem.  It  would  seem  from  our  experience  that  there  is  force  in  the 
allegation  that  those  sleeping  in  second  stories  are  less  liable  than  those  sleeping  in  the  lower 
strata  of  the  atmosphere.  By  letters  addressed  by  the  President  to  the  mayors  of  the  cities  and 
towns  on  the  Mississippi  and  Red  rivers,  it  was  ascertained  that  cholera  appeared  in  St.  Louis 
on  the  3d  of  August,  at  Memphis  on  the  8th,  at  Baton  Rouge  August  1st,  Natchez  on  the  7th,  at 
Shreveport  on  the  12th;  at  Vicksburg  it  had  not  appeared  on  the  13th,  at  Alexandria  on  the 
25th.  The  newspapers  reported  it  at  Fort  Kearney  on  the  27th  of  August,  all  arriving  on  steam- 
boats from  this  city.  Thus,  it  will  be  seen  by  this  detail  that  cholera  appeared  in  this  city  on 
the  22d,  if  not  before;  it  was  confined  at  first  to  one  locality,  and  then  for  several  days  to  two; 
that  about  the  5th  of  August  it  had  extended  itself  throughout  the  city  ; that  it  was  carried  by 
steamboats,  either  by  means  of  persons  or  goods,  to  St.  Louis  by  the  time  that  it  reached  the 
lower  part  of  this  city ; that  it  reached  there  before  it  manifested  itself  in  the  towns  below. 

In  short,  it  would  appear  that  an  influence,  or  substance,  or  germ,  was  introduced  into  this  city 
from  without,  that  it  developed  itself  here  into  epidemic  dimensions,  and  that  from  this  city  it 
was  propagated  throughout  the  Mississippi  Valley,  by  means  of  commercial  intercourse.”* 

The  deaths  from  Asiatic  cholera  were  as  follows:  July,  30;  August,  569;  September,  456;  ] 
October,  166;  November,  47;  December,  26.  Total  deaths  from  Asiatic  cholera,  1294.  During 
the  period  extending  from  June  1st  to  Jan.  1st,  1867,  cholera  infantum  caused  78,  and  cholera  j 
morbus  91  deaths.  There  were  188  deaths  by  variola  and  varioloid.  The  total  deaths  from  all  3 
causes  for  the  year  1866  were  7754.  The  highest  number  of  deaths  by  cholera  upon  any  single  day 
occurred  on  the  15th  of  August,  when  46  deaths  were  reported  as  due  to  this  disease. 

YELLOW  FEVER  AND  CHOLERA  OF  1867. 

In  1867,  yellow  fever  appeared  in  June;  the  first  case  died  in  the  Charity  Hospital  on  the  10th  of 
this  month.  The  Board  of  Health  were  unable  to  trace  its  introduction  from  without.  Tho  fever 
existed  throughout  July,  in  the  city,  and  until  near  the  middle  of  August,  before  acquiring  epi- 
demic proportions. 

Every  house  where  a case  was  reported  as  having  occurred  was,  under  tho  direction  of  the 
health  officers,  cleansed  and  fumigated  with  sulphurous  acid  gas  and  carbolic  acid ; the  premises 
likewise  were  subjected  to  tho  provisions  of  the  health  ordinance,  and  the  privies  purified  by  the 
sulphate  of  iron.  Notwithstanding  these  measures  the  disease  became  epidemic,  an  immense 
number  of  cases  occurred,  and  3107  deaths  were  reported  as  directly  caused  by  yellow  fever,  in 
addition  to  990  deaths  caused  by  the  various  forms  of  paroxysmal  and  continued  fever.  The 
President  of  the  Board  of  Health,  Dr.  S.  A.  Smith,  affirmed  that  the  action  of  the  cause  of  yellow 
fever  was  never  before  more  genoral  upon  the  population.  Very  few  of  the  susceptible  escaped, 
yet  the  mortality  from  it  was  exceedingly  small,  estimated  as  to  the  number  of  inhabitants,  and 
particularly  as  to  the  number  of  cases.  The  number  of  susceptible  subjects  was  larger  from  there 
having  been  no  epidemio  since  1858,  so  that  all  children  under  eight  years  were  susceptible.  Dr. 
Smith  says:  “Tho  smallness  of  tho  mortality  may  bo  attributed  in  groat  part  to  there  being  little 
immigration  from  Europe,  and  from  the  large  increase  in  colored  people,  in  whom  the  tendency 
of  the  disease  is  to  recovery.” 

Tho  first  case  of  yellow  fever  died  in  the  Charity  Hospital  on  the  10th  of  June;  a seaman 
who  had  been  employed  in  the  navigation  of  the  lake.  Three  weeks  before  his  death  he  had 
shipped  upon  the  bark  “ Bessie,”  loading  with  staves  in  the  Fourth  District  and  bound  for  Barcelona. 
This  vessel  had  sailed  from  Havana  in  March,  arriving  in  New  Orleans  in  April,  laden  with 


* “ Report  of  the  Board  of  Health  to  the  Legislature  of  the  State  of  Louisiana,  1867,”  p.  6. 


SECTION'  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  389 


sugar.  She  was  reported  clean  and  healthy.  Soon  after  arriving  went  into  dry  dock,  in  Algiers. 
Inquiries  were  made  concerning  her  after  her  sailing.  She  arrived  at  her  destination  without  mis- 
hap as  to  the  lives  of  her  crew.  The  second  case  was  reported  by  Dr.  Brickell  as  having  been  taken 
on  the  13th  of  June,  on  St.  Charles  street,  near  Julia.  The  man  recovered.  The  third  case, 
reported  by  Dr.  Folwell,  on  Julia  street,  between  Camp  and  St.  Charles  streets,  died  on  the  23d  of 
June.  The  fourth  case  died  on  the  26th  of  June  ; ho  arrived  upon  the  steamer  from  Galveston  on 
the  21st,  whence  he  came  from  Indianola  direct.  He  had  a chill  at  Galveston  on  the  19th,  and 
died  on  the  26th.  The  fifth  case  died  on  the  26th  of  June  in  the  Charity  Hospital.  He  came 
from  61  Girod  street,  and  was  employed  on  coal  barges  at  Algiers.  The  sixth  case  was  Lieut. 
Dewey,  who  died  at  the  St,  Charles  Hotel.  Ho  came  by  steamer  direct  from  Indianola,  and  was 
brought  from  the  vessel  to  the  hotel  sick. 

The  first  vessel  coming  to  New  Orleans  clearly  infected  was  the  bark  “ Florence  Peters,”  which 
sailed  from  Havana  on  the  3d  of  June,  laden  with  sugar.  She  was  stopped  at  the  quarantine 
station  June  12th,  where  she  was  detained  ten  days,  although  reported  clean  and  healthy;  was 

1 fumigated  and  released.  She  arrived  at  Algiers  June  22d.  The  wife  of  the  captain,  Mrs. 
Hooper,  died  of  yellow  fever  on  the  30th.  This  case  was  reported  by  Dr.  Burns.  Her  sister  also 
was  attacked  on  the  25th,  but  recovered.  The  second  mate  was  taken  July  4th,  and  died  in  the 
i Charity  Hospital  on  the  9th.  The  captain  died  on  the  13th. 

The  fever  was  not  originally  introduced  by  this  vessel,  as  the  first  death  occurred  in  the 
Charity  Hospital  on  the  10th  of  June,  and  was  probably  seized  with  the  fever  about  the  5th  of  this 
month;  notwithstanding  this,  it  is  probable  that  the  bark  “Florence  Peters  ” was  a separate  centre  of 
infection.  Although  the  fever  had  commenced  early  in  June,  and  had  existed  throughout  July, 
it  did  not  acquire  epidemic  proportions  until  near  the  middle  of  August;  and  this  slow  progress 
would  appear  to  have  been  highly  favorable  to  the  arrest  of  the  disease  by  the  early,  energetic  and 
thorough  use  of  disinfectants. 

With  reference  to  the  efforts  made  to  arrest  the  disease  by  sanitary  measures,  Dr.  S.  A.  Smith, 
President  of  the  Board  of  Health,  says:  “Every  house  where  a case  was  reported  as  having 
occurred  was,  under  the  direction  of  the  health  officers,  cleansed  and  fumigated  with  sulphurous 
acid  gas  and  with  carbolic  acid.  The  premises  likewise  were  subjected  to  the  provisions  of  the 
health  ordinance,  and  the  privies  purified  by  sulphate  of  iron.”  Notwithstanding  the  failure  of 
these  measures,  which  were  subsequently,  by  the  successors  of  Dr.  S.  A.  Smith,  vigorously  pushed, 
the  President  of  the  Board  of  Health  expressed  the  belief  that — 

“ The  slow  development  of  the  cause  of  the  fever,  its  apparent  temporary  suspension  in  par- 
ticular localities,  the  exceedingly  mild  character  of  the  pestilence,  leads  to  the  hope  that  it  may  be 
kept  in  check,  if  not  entirely  eradicated  in  the  first  cases,  by  the  prompt  application  of  disin- 
i fectants.” 

The  comparatively  slow  spread  of  the  yellow  fever  of  1867  is  shown  by  the  following  record  of 
deaths  for  the  respective  months:  June,  3;  July,  11;  August,  255;  September,  1637;  October, 
1072  ; November,  103 ; December,  23.  Total,  3107. 

The  highest  mortality  occurred  on  the  23d  of  September,  when  the  total  deaths  from  all  causes 
amounted  to  133,  82  of  which  were  caused  by  yellow  fever,  17  by  other  kinds  of  fever,  and  41  by 
0 cholera. 

General  reports  were  made  by  the  health  officers  only  of  the  Second  and  Third  Districts. 

Dr.  E.  S.  Lewis,  Health  Officer  of  the  Third  District,  in  his  official  report  to  Dr.  S.  A.  Smith, 
President  of  the  Board  of  Health,  thus  gives  the  results  of  his  attempts  to  arrest  the  spread  of 
cholera  and  yellow  fever  by  “fumigants  and  disinfectantn.” 

“During  the  month  of  May,  until  about  the  latter  part  of  June,  my  district  was  exempt  from 
I epidemic  diseases,  and  consequently  neither  fumigants  nor  disinfectants  were  employed.  From 
that  time  until  August,  true  cholera  appeared  in  the  district;  the  first  case,  originating  corner  of 
Mandeville  and  Prosper  streets,  terminated  fatally  in  the  Charity  Hospital.  This  place  was  not 
immediately  disinfected,  and  soon  the  whole  neighborhood  from  Elysian  Fields  to  Mandeville,  on 
Prosper,  Josephine,  Solidelle,  Morales  and  Urquhart  streets  was  thoroughly  infected  with  cholera, 
about  twenty-five  cases  occurring  in  a week.  Requisitions  for  disinfectants  were  made  and  for- 
warded to  the  Street  Commissioner,  and  about  the  10th  of  July  over  thirty  houses  in  the  locality 
mentioned  were  thoroughly  fumigated  and  disinfected.  From  that  time  not  more  than  two  or 
three  cases  originate!  in  that  part  of  the  district.  Other  cases  were  afterward  reported  in  various 


390 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


portions  of  the  district — on  Greatman  street,  Congress,  Cascairo  and  Front  Levee,  but  the  infected 
houses  were  promptly  attended  to,  and  the  cholera  was  effectually  checked.  I have  no  hesitation 
in  stating  that  it  was  checked,  for  I observed  that  wherever  the  work  of  purifying  infected  houses 
was  delayed,  whether  from  want  of  promptness  on  the  part  of  physicians  in  reporting  their  cases, 
or  from  other  cases  occurring  in  the  same  places,  the  adjoining  houses  suffered,  which  did  not 
prove  tho  case  when  nothing  interfered  with  or  obstructed  mo  in  my  duty. 

“Though  I cannot  assert  so  positively  on  the  beneficial  effects  of  disinfectants  during  the  pre- 
valence of  yellow  fever,  I firmly  believe  that  yellow  fever  can  be  checked,  but  for  that  purpose  a 
removal  of  the  sick  would  be  necessary,  especially  the  first  cases,  and  a better  knowledge  on  the 
part  of  tho  practitioners  of  medicine  generally  of  the  disease,  so  that  the  early  cases  would  not 
escape  notice. 

“ The  number  of  houses  disinfected  of  yellow  fever  from  the  middle  of  August  to  November  1st, 
was  about  three  hundred.  The  first  case  died  in  the  Hospital,  but  was  taken  there  from  Antonio 
Baptistella’s,  on  Victory  street,  near  Elysian  Fields.  Four  days  afterward  there  were  upward  of  forty 
cases  on  Victory,  from  Frenchman  to  Elysian  Fields  streets.  Every  house  is  a boarding  house, 
and  many  were  filled  to  overflowing  with  strangers.  These  houses  were  not  only  fumigated  with 
sulphur  and  disinfected  with  sulphate  of  iron  in  solution,  but  were  pumped  from  top  to  bottom 
with  carbolic  acid,  which  impregnated  the  atmosphere  for  some  distance  off.  This  was  repeated 
as  often  as  new  cases  occurred.  From  the  1st  of  September  to  the  present  time  there  has  not  been 
a more  healthy  neighborhood,  and  notwithstanding  new  sets  of  boarders  have  taken  the  places  of 
those  who  have  gone  away,  also  equally  unacclimated,  but  very  few  to  my  knowledge  have  been 
sick  with  yellow  fever.”'* 

During  the  subsequent  seven  years,  in  which  carbolic  acid  was  largely  used  by  the  Board  of 
Health  of  New  Orleans  for  the  limitation  and  eradication  of  yellow  fever,  the  views  of  Professor 
E.  S.  Lewis,  m.  D.,  underwent  a decided  and  radical  change. 

Thus,  at  a “ Meeting  of  Physicians  to  Discuss  Carbolic  Acid,”  held  in  New  Orleans,  Septem- 
ber 29th,  1875,  Professor  Ernest  S.  Lewis  made  the  following  statement  :f — 

“The  subject  under  discussion,  or  carbolic  acid  disinfection  as  at  present  carried  out,  may  be 
considered  under  two  heads. 

“ 1.  As  to  whether  it  destroys  tho  germs  of  yellow  fever  and  prevents  its  spread ; and  secondly, 
as  to  whether  its  use  is  not  injurious  to  those  sick  with  the  fever,  and  to  the  delicate  with  inherited 
or  natural  tendencies  to  diseases  of  the  brain,  heart,  lungs  and  urinary  organs. 

“ Taking  into  consideration  the  first  division  of  the  subject,  I will  state  that  its  use,  or  rather 
abuse,  is  not  of  very  recent  date  in  tho  history  of  our  Boards  of  Health;  for  as  far  back  as  1S67, 
at  which  time  I was  health  officer,  not  only  under  my  supervision  were  yards,  privies,  and  gutters 
thoroughly  disinfected,  but  by  means  of  a pump  it  was  thrown  over  the  floors,  walls  -and  ceilings  of 
the  houses,  with  the  hope  that  the  germs  might  be  destroyed  and  the  fever  arrested.  It  had  no 
effect  whatever ; the  disease  soon  extended  to  every  part  of  the  city  in  the  most  rapid  manner — 
under  the  ‘ genius  epidomicus,’ if  you  will — which  favored  the  rapid  propagation  of  the  yellow 
fever  germs;  and  if  since  then  no  epidemics  have  occurred,  it  is  unquestionably  because  the  neces- 
sary conditions  have  not  been  present.  It  has  at  no  time,  however,  been  rooted  out  of  the  city, 
and  if  my  memory  serves  me  right,  this  is  the  first  year  since  the  great  epidemic  during  which  I ■ 
have  not  had  cases  under  treatment.  If,  then,  carbolic  acid  is  such  an  effective  agent  in  the  sup- 
pression of  yellow  fever,  why  should  the  disease  not  stop  short  at  the  first  cases,  when  upon  its 
first  appearance  such  extraordinary  measures  are  adopted  for  its  arrest?  It  should  not  extend 
beyond  the  focus  of  infection;  and  yet  wo  hear  of  its  existence  in  different  localities  presenting 
all  the  requisites  in  the  way  of  numerous  foci  of  infection  for  its  epidemic  spread,  excepting  tho 
most  necessary — that  which  I stated  was  formerly  designated  as  the  * genius  epidemicus,'  or 
‘ constitute  pestilens.’ 

“ I do  not  question  the  usefulness  of  carbolic  acid  as  a purifying  agent  in  arresting  fermenta- 
tive processes  in  decomposing  vegetable  and  nnimal  substances,  but  to  accomplish  this  there  must 
be  contact  of  the  acid  in  a state  of  solution,  and  not  in  a vaporous  condition  . . . 


* “Annual  Report  of  the  Board  of  Health  to  the  Legislature  of  the  State  of  Louisiana,”  January,  1S68, 
pages  12, 13. 

f The  New  Orleans  Medical  and  Surgical  Journal,  N.  S.,  Vol.  HI,  No.  3,  November,  1875,  pages  431-434. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  391 


“Another  author,  Prof.  Ringer, of  London,  remarks  as  follows:  ‘Its  destructive  influence  over 
the  low  forms  of  animal  and  vegetable  life  has  led  to  its  being  considered  a disinfectant,  but  no 
satisfactory  proof  exists  of  its  capacity  to  destroy  the  contagious  elomonts  of  disease.’ 

“ In  my  opinion,  its  efficacy  is  as  questionable  and  as  irrational  as  the  following  suggestion  of 
an  author  of  the  seventeenth  century,  enthused  with  the  parasitic  theory  of  the  origin  of  diseases, 
that  the  people  should  sally  forth  in  the  infected  districts,  and  by  sounding  horns  and  firing  can- 
non repel  the  invaders,  which  he  likened  to  a cloud  of  locusts. 

“ Tho  2d  proposition,  as  to  whether  its  use  is  injurious  or  not  to  the  community,  will  now 
be  considered. 

“ In  the  first  place,  we  have  met  together,  to-night,  not  so  much  to  discuss  the  efficacy  of  car- 
bolic acid  in  arresting  the  spread  of  yellow  fever,  for  if  that  were  all,  we  could  offer  no  reasonable 
i objections  to  its  use  as  a legitimate  experiment,  in  the  interests  of  science,  but  our  individual 
i experience  has  unfortunately  brought  to  our  notice  many  instances  of  its  deleterious  action,  when 
even  life  itself  has  paid  the  forfeit.  Such  cases  have  been  reported  in  the  preceding  meetings, 
held  in  the  Second  District,  and  it  cannot  be  wondered  at  that  such  serious  opposition  to  its  use 
should  be  manifested  by  the  disinterested  members  of  the  medical  profession.  Numbers  of  persons 
living  on  those  streets  where  this  toxic  agency  was  thrown,  have  been  affected  in  various  ways, 
with  giddiness,  nausea,  vomiting,  diarrhoea,  a sense  of  suffocation;  in  other  words,  with  manifes- 
tations of  its  poisonous  action.” 

After  quoting  various  authors  with  reference  to  the  poisonous  effects  produced  by  carbolic  acid, 
Professor  Ernest  S.  Lewis,  m.d.,  concludes  with  the  following  observation : — 

“These  few  instances  cited,  and  the  many  others  reported  in  various  journals,  prove  that  this 
< powerful  substance  is  used  too  rashly  in  medicine  and  in  surgery,  and  the  Board  of  Health,  no 
i doubt  actuated  by  the  best  of  motives,  would  do  well  to  bear  in  mind  that  individual  susceptibili- 
ties can  make  of  its  vapor,  in  a state  of  atmospheric  dilution,  a fatal  poison  to  many.” 

In  view  of  the  preceding  statement,  it  appears  remarkable  that  when  under  the  immediate 
■ supervision  of  Dr.  E.  S.  Lewis,  in  1867,  “ houses  were  not  only  fumigated  with  sulphur  and  dis- 
: infected  with  sulphate  of  iron  in  solution,  but  were  pumped  from  top  to  bottom  with  carbolic  acid, 
which  impregnated  the  atmosphere  for  some  distance  off,”  no  injurious  or  pernicious  effects  induced 
r by  carbolic  acid  were  recorded  by  the  zealous  and  energetic  health  officer  of  the  Third  District,  in 
i his  official  report  to  the  Board  of  Health. 

SDr.  Alfred  W.  Perry,  Health  Officer,  Second  District,  made  the  following  statement  on  the 
3d  of  December,  1867,  to  Dr.  S.  A.  Smith,  President  of  the  Board  of  Health,  with  reference  to  his 
use  of  disinfectants  for  tho  arrest  of  yellow  fever,  during  the  months  of  July,  August,  September, 
I October  and  November : — 

“ Up  to  the  4th  of  August,  1867,  the  amount  of  disinfection  required  was  performed  by  police 
officer,  II.  Tricon,  detailed  from  the  police  force  of  this  district.  The  number  of  cases  of  yellow 
i fever  increasing,  I made  application  to  the  Deputy  Street  Commissioner  of  Second  and  Third  Dis- 
H tricts,  Mr  L.  C.  de  Homorgue,  who  supplied  me  with  two  men,  who  have  been  employed  in  disin- 
fecting, inspecting  and  serving  notices.  I have  always  found  this  officer  ready  to  furnish  any 
i assistance  in  the  execution  of  sanitary  measures,  and  an  ample  supply  of  disinfectants  was  always 
■ kept  on  hand  by  the  department.  During  tho  existence  of  yellow  fever  here,  about  334  cases  were 
) reported  to  me  as  having  died  in  this  district.  Out  of  this  number,  293  houses  had  one  death  in 
■1  each;  12  houses  had  two  deaths;  four  houses  had  three;  one  house  had  five  deaths. 

“ The  mode  of  disinfection  was  by  closing  the  room  or  chamber  in  which  the  death  took  place, 
tightly  stopping  up  the  fireplaces  and  burning  two  to  four  pounds  of  sulphur  in  the  apartment, 
which  also  was  generally  sprinkled  with  carbolic  acid.  Sulphate  of  iron  was  put  in  the  privies  and 
i mixed  with  the  excreta,  and  all  bed  clothes  boiled  or  destroyed.  During  the  period  embraced  by 
this  report  46  deaths  from  cholera  took  place  in  45  houses,  only  one  house  having  had  a second  case. 

“ I have  studiously  avoided,  in  this  report,  giving  any  opinion  or  theory  as  to  the  causation  or 
mode  of  propagation  of  cholera  or  yellow  fever,  or  of  the  efficiency  of  disinfection  therein.  I simply 
" report  the  means  adopted  by  me,  and  the  results  obtained,  from  which,  of  course,  you  can  make 
the  proper  deductions.”  * 


•“Annual  Report  of  the  Board  of  Health,  January,  1868,”  p.  10. 


392 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


During  the  year  1867,  the  following  deaths  were  caused  by  the  various  forms  of  fever : Fever, 
22;  bilious,  45;  congestive,  278;  pernicious,  255;  intermittent,  51;  brain,  39;  nervous,  13;  puer- 
peral, 11;  remittent,  110;  scarlet,  12;  malignant,  12;  gastric,  1;  typhoid,  119;  typhus,  23;  total 
by  fevers,  exclusive  of  yellow  fever,  1001  ; total  deaths  by  yellow  fever,  3107 ; total  deaths  from  all 
fevers,  4108.  Without  doubt,  a portion  of  the  cases  reported  as  congestive,  pernicious,  remitlent 
and  typhoid  fevers,  were  in  reality  yellow  fever.  The  deaths  from  these  forms  of  fever  numbered 
alone  762,  and  they  occurred  chiefly  in  those  months  in  which  yellow  fever  was  most  fatal,  namely, 
deaths  from  these  fevers,  January,  14;  February,  10;  March,  15;  April,  6;  May,  13;  June,  38; 
July,  53;  August,  144;  September,  195;  October,  190;  November,  57  ; December,  27. 

Smallpox  and  varioloid  caused  47  deaths,  and  Asiatic  cholera,  581  deaths;  cholera  infantum, 
100 ; cholera  morbus,  46  ; congestion  of  bowels,  13 ; diarrhoea,  acute  and  chronic,  205  ; dysentery, 
acute  and  chronic,  180;  entero-colitis,  36;  diphtheria,  31.  Bowel  affections,  therefore,  were  581 
deaths,  or  precisely  the  same  number  as  Asiatic  cholera ; the  total  deaths  from  all  the  various  affec- 
tions of  the  bowels  being  1162. 

The  total  deaths  for  the  year  1867  were  10,096,  and  of  this  number  5270,  or  more  than  one-half, 
were  caused  by  fevers  and  bowel  affections,  and  the  deaths  caused  by  the  two  diseases  generally 
regarded  as  exotic  and  of  foreign  origin,  namely,  yellow  fever  and  Asiatic  cholera,  were  3688, 
or  one  death  in  2.7  deaths  from  all  causes.  If  the  deaths  caused  by  the  various  forms  of  fever  as 
reported,  but  really  caused  by  yellow  fever,  and  those  caused  by  cholera,  but  reported  under  differ- 
ent diseases  of  the  bowels,  as  cholera  infantum,  cholera  morbus  and  diarrhoea,  are  added  to  those 
officially  charged  to  cholera  and  yellow  fever,  it  would  approximate  more  nearly  to  the  truth  to 
refer  about  one-half  of  the  ten  thousand  and  ninety-six  deaths  of  1867  to  these  two  diseases  alone. 

It  cannot  therefore  be  said  that  disinfection  and  sanitary  work,  as  conducted  by  the  Board  of 
Health  in  1867,  had  any  recognizable  effect  in  arresting  either  yellow  fever  or  cholera. 

On  the  other  hand,  there  appeared,  as  had  been  observed  in  this  city  before,  some  unknown 
relationship  or  influence  between  the  causes  inducing  yellow  fever  and  cholera.  Thus,  the  Presi- 
dent of  the  Board  of  Health  observes : — 

“ The  cholera  introduced  in  1866  maintained  its  existence  throughout  the  year  1867,  receding 
in  its  influence  as  the  yellow  fever  advanced,  and  again  exciting  alarm  by  the  number  of  its  vie-  j 
tims,  as  the  yellow  fever  subsided.  There  were  reported  234  deaths  from  it  alone  in  November,  and 
210  in  December.”  * 

During  1867,  the  cases  of  yellow  fever  admitted  to  the  Charity  Hospital  f numbered  1493,  and 
the  deaths  from  this  disease,  672,  or  one  death  in  2.29  cases.  The  following  cases  and  deaths  of 
other  forms  of  fever  occur  upon  the  Charity  Hospital  Record  for  1867 : Intermittent  cases,  2225, 
deaths,  13;  remittent  cases,  296,  deaths,  28;  malarial  cases,  298,  deaths,  31;  typhoid  cases,  39, 
deaths,  18;  congestive,  43,  deaths,  35  ; continued  cases,  11,  deaths,  2 ; dengue  cases,"  3.  Of  bowel 
affections:  Cholera,  94  cases,  70  deaths;  cholera  morbus,  13  cases;  cholera  infantum,  1 case,  1 death; 
diarrhoea,  acute,  271  cases,  23  deaths;  diarrhoea,  chronic,  cases,  88,  deaths,  35;  dysentery,  acute, 
179  cases,  35  deaths;  dysentery,  chronic,  80  cases,  36  deaths.  The  total  admissions  into  the 
Charity  Hospital  for  1867  were  8612,  and  the  total  deaths,  1438.  Yellow  fever  and  cholera  alone 
caused  742  deaths,  or  a little  more  than  one-half  the  deaths  from  all  causes.  The  statistics  of  these 
two  diseases,  with  reference  to  the  total  mortality,  as  furnished  by  the  Charity  Hospital,  corres-  i 
ponded  to  a marked  degree  with  those  of  the  city  at  large.  It  is  not  known  that  any  measures 
of  disinfection  were  practiced  in  the  Charity  Hospital. 

' 

YELLOW  FEVER  OF  186S  AND  1869. 

In  the  Mortuary  Report  of  the  Board  of  Health  J for  1868,  only  three  deaths  are  recorded  as 
caused  by  yellow  fever,  while  upon  the  reports  of  the  Charity  Hospital  8 cases  are  recorded,  with 
5 deaths.  Wo  have  no  information  as  to  the  origin  or  history  of  these  cases.  During  a portion  of 
1868,  the  Board  of  Health  appears  to  have  been  in  an  unsatisfactory  condition,  on  account  of  the 
assumption  of  the  offices  of  the  State  of  Louisiana  by  the  Radical  party,  sustained  by  the  negro 


*“  Annual  Report  of  the  Board  of  Health,  January,  18G8,"  p.  4. 

f“  Report  of  the  Board  of  Administrators  of  the  Charity  Hospital  to  the  Legislature  of  the  State  of 
Louisiana,”  July,  18G8. 

1 The  Hew  Orleans  Journal  of  Medicine,  Vol.  xxiii,  No.  2,  April,  1870,  p.  398. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  393 


vote  under  the  leadership  of  H.  C.  Warmoth.  In  the  annual  report  of  the  Board  of  Health,  De- 
cember 31st,  1S69,  the  following  statement  occurs,  which  explains  the  relations  of  the  new  (Radical) 
to  the  old  Board  of  Health  : — 

“The  members  of  the  Board  of  Health  commissioned  by  his  Excellency,  Governor  II.  C. 
Warmoth,  took  their  seats  November  6th,  1868.  To  give  the  Common  Council  of  New  Orleans 
opportunity  to  fill  the  vacancy  caused  by  the  death  of  a member  appointed  by  the  city,  the  election 
of  permanent  officers  was  postponed  to  November  13th,  1868,  at  which  time,  C.  B.  White,  M.D.,was 
elected  President  and  S.  C.  Russell,  m.d.,  Secretary.  The  members  of  the  Board  of  Health  whose 
positions  were  vacated  by  the  appointment  of  their  successors  by  Governor  Warmoth,  and  the  two 
members  holding  over  by  virtue  of  their  appointment  by  the  city,  refused  to  give  possession  to  the 
Board  of  Health,  as  reorganized,  of  either  office,  books,  or  money,  encouraged  the  bringing  of  suits 
at  law  against  the  Board,  injured  its  credit,  caused  much  needless  expense,  and  only  yielded  to  the 
process  of  law.” 

The  following  deaths  were  caused  by  the  various  forms  of  fever  during  1868:  Fever,  109  ; bil- 
ious, 19  ; congestive;  105;  brain,  17;  intermittent,  15;  malarial,  4;  nervous,  7;  pernicious,  67; 
puerperal,  9;  remittent,  26;  scarlet,  14;  malignant,  1;  typhoid,  5S  ; typhus,  5;  total  by  fevers, 
excluding  yellow  fever,  436  ; including  all  fevers,  441. 

Cholera  caused  129  deaths;  cholera  infantum,  85  ; cholera  morbus,  22;  diarrhoea,  acute  and 
chronic,  112;  dysentory,  acute  and  chronic,  161;  inflammation  of  bowels,  30;  total  diseases  of 
bowels,  419. 

The  total  number  of  deaths  during  1S68,  as  officially  reported  by  the  Board  of  Health,  was 
5343.  In  1846,  the  total  deaths  amounted  to  4500,  but  from  that  period  up  to  1868  they  had 
annually  exceeded  the  number  which  was  reported  in  the  latter  year.  It  is  possible  that  the  un- 
usual small  mortality  of  1868  may  have  been  in  some  way  associated  with  the  heavy  mortality  of 
the  preceding  year.  The  difficulties  in  the  Board  of  Health  did  not  appear  either  to  promote  the 
spread  of  yellow  fever  or  cause  a higher  death  rate. 

49S1  patients  were  admitted  to  the  Charity  Hospital,  and  the  deaths  in  this  institution  num- 
bered 490.  The  fevers  treated  in  the  Charity  Hospital  were  as  follows  : Intermittent  cases,  995, 
deaths,  5 ; malarial  cases,  410,  deaths,  11 ; yellow  fever  cases,  8,  deaths,  5 ; remittent  cases,  118; 
congestive  cases,  10,  deaths,  8 ; scarlet  cases,  2,  deaths,  1 ; bilious  case,  1 ; pernicious  cases,  8,  deaths, 
8 ; typhoid  cases.  17,  deaths,  S.  Of  cholera,  15  cases,  9 deaths;  cholera  morbus,  12  cases,  1 death; 
diarrhcea,  154  cases,  27  deaths  ; dysentery,  197  cases  and  48  deaths.  In  the  city  smallpox  caused 
14  deaths,  and  diphtheria  16  deaths. 

YELLOW  FEVER,  1869. 

On  July  17th,  Peter  Tabam  was  taken  sick  with  yellow  fever;  two  days  in  the  city, twelve  days 
from  Havana,  eight  of  which  he  was  detained  at  quarantine.  He  died  with  black  vomit  on  the 
19th.  The  house  was  taken  charge  of  by  the  Sanitary  Police,  under  the  supervision  of  Dr.  Perry, 
Health  Officer.  The  bedding  and  clothing  of  deceased  were  burned,  the  house  fumigated  with 
sulphurous  acid,  and  drains  and  vaults  disinfected  with  sulphate  of  iron  and  carbolic  acid. 

On  August  26th,  a case  considered  by  the  attending  physicians  to  bo  yellow  fever,  was  reported 
on  Royal  street,  and  was  removed  to  the  Hospital  of  the  French  Benevolent  Society.  When  seen 
by  members  of  the  Board  of  Health,  on  the  eighth  day  of  the  disease,  he  was  very  yellow,  had  epi- 
gastric tenderness,  red  and  spongy  gums,  albumen,  but  no  bile  in  urine.  He  recovered  slowly  and 
with  difficulty.  This  patient  stated  that  he  had  yellow  fever  in  1858,  at  Pascagoula. 

On  September  30th,  the  captain  of  the  British  ship  “ Belgravia”  was  taken  sick,  and  the  next 
two  days  two  boys  belonging  to  the  crew.  The  captain  had  a severe  paroxysm  of  fever  of  twenty- 
four  hours’  duration,  leaving  him  much  prostrated,  with  conjunctiva:  yellow,  and  gums  red  and 
easily  bleeding.  He  stated  that  he  had  an  attack  of  yellow  fever  twenty  years  before,  in  Per- 
nambuco. 

The  two  boys  before  mentioned  were  taken  to  tho  Charity  Hospital.  One  died  on  the  fourth 
day  of  the  disorder,  the  other  recovered.  Both  had  black  vomit  largely,  and  presented  all  the 
customary  symptoms  of  yellow  fever.  They  were  typical  cases. 

The  “ Belgravia  ” was  direct  from  Liverpool ; cargo  principally  salt  and  crates  of  crockery. 
Had  not  been  within  fifteen  miles  of  land  on  her  passage.  Her  previous  voyage  was  from  this 
port  to  Liverpool.  In  coming  up  the  Mississippi  river  the  “Belgravia”  had  not  come  in  contact 
with  vessels  from  tho  yellow  fever  ports,  nor  did  any  such  crafts  lie  near  her,  before  the  appoar- 


394 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ancc  of  these  eases  of  sickness.  The  captain  of  the  ship  had  quarters  in  town,  several  blocks  from 
the  ship;  the  boys  stayed  on  shipboard. 

Another  case  of  yellow  fever  was  brought  to  the  Charity  Hospital  on  the  8th  of  October,  from 
a British  ship  which  had  been  lying  in  this  port  one  month,  and  had  come  direct  from  Liverpool. 
The  case  was  considered  well  marked,  and  resulted  in  recovery.'* 

H.  D.  Baldwin,  m.d.,  resident  physician  at  quarantine,  furnishes  the  following  statement  of  cases 
of  infected  ships  and  number  of  cases  of  yellow  fever  which  arrived  from  foreign  ports  after  the 
issuing  of  the  Executive  proclamation,  May  15th,  1S69  : — — 

The  sick  were  taken  from  the  vessels,  placed  in  the  hospital,  and  the  vessels  thoroughly  fumi- 
gated, and  only  allowed  to  proceed  after  such  detention  and  thorough  cleansing  as  would  prevent 
their  carrying  infection. 

Schooner  “Andromeda,”  arrived  from  Havana  the  last  week  in  June ; one  case,  sailor.  Recovered. 

Schooner  “Jacinto,”  from  Tampico,  August  3d;  three  cases.  Recovered. 

Schooner  “Cecilia,”  from  Tampico,  August  19th;  two  cases.  Recovered. 

Steamship  “Trade  Wind,”  from  Belize,  September  19th;  two  cases.  One  death. 

Bark  “Aureliana,”  from  Havana,  October  30th;  one  case.  Died. 

Forty-one  vessels,  arriving  from  ports  declared  infected  by  proclamation,  were  quarantined, 
thoroughly  fumigated,  and  allowed  to  proceed  only  after  detention  required  by  law.f 

From  the  preceding  account,  as  officially  published  by  the  Board  of  Health,  we  gather  that  dis- 
infection and  destruction  of  clothes  and  bedding  were  practiced  in  the  first  case,  but  not  in  the 
subsequent  ones.  Although  three  cases  were  traced  to  the  British  ship  “ Belgravia,”  the  captain  and 
two  boys,  we  have  no  record  of  any  fumigation  or  disinfection  of  this  vessel ; and  yet  the  fever 
did  not  spread  either  in  the  port  among  the  shipping  or  in  the  city.  The  cases  occurring  upon 
the  “ Belgravia  ” appear  to  have  been  sporadic  or  of  local  origin,  and  could  not  be  traced  to  any  for- 
eign origin. 

Upon  the  Mortuary  Reports  of  the  Board  of  Health,  1869,  only  three  deaths  were  recorded  as 
due  to  yellow  fever,  one  in  July  and  two  in  October. 

The  various  forms  of  fever  caused  the  following  deaths:  Fever,  2;  bilious,  12;  congestive, 
118;  pernicious,  110 ; intermittent,  32 ; brain,  26;  nervous,  5;  puerperal,  20  ; remittent,  36 ; 
scarlet,  13;  malarial,  24;  gastric,  3;  typhoid,  63;  typhus,  5;  yellow,  3;  total  deaths  from  fever, 
472.  Cholera  infantum  and  cholera  morbus  caused  only  65  deaths ; diarrhoea,  115;  dysentery, 
158;  inflammation  of  bowels,  95.  Total  from  these  bowel  affections,  423.  Diphtheria,  19  deaths. 
Smallpox  and  varioloid,  141.  Smallpox  caused  32  deaths  in  November  and  88  deaths  in  Decem- 
ber. The  total  number  of  deaths  in  1869,  6001. 

In  the  Charity  Hospital,  0177  patients  were  admitted  and  784  died.  Three  cases  of  yellow 
fever  were  reported,  with  one  death.  The  admissions  and  deaths  from  the  various  forms  of  fever 
in  the  Charity  Hospital  were  as  follows:  Intermittent,  cases  1391,  deaths,  7 ; malarial  cases,  291; 
congestive,  34  deaths;  remittent,  48  cases,  4 deaths;  typhoid,  16  deaths,  19  cases;  bilious,  7 
cases;  ephemeral,  1;  yellow  fever,  3 eases,  1 death;  catarrhal,  1 case;  typho-malarial,  27  deaths; 
typhus,  1 death;  puerperal,  2.  With  reference  to  the  various  classes  of  fevers,  the  records  of  the 
Charity  Hospital  appear  to  have  been  kept  in  a loose  and  unsatisfactory  manner,  and  the  chief 
fault  appears  to  have  rested  with  the  time  and  mode  of  entering  the  diagnosis  of  the  cases  by  the 
attending  physicians  and  surgeons.  These  irregularities  are  shown  thus:  13  cases  of  congestive 
fever  are  reported  as  admitted,  with  34  deaths;  15  cases  of  typhoid  and  16  deaths;  no  cases  of 
typho-malarial  fever  and  27  deaths  entered  as  caused  by  this  disease.  Dysentery,  acute,  58  cases, 
8 deaths;  dysentery,  chronic,  24  eases,  49  deaths  ; diarrhoea,  acute,  109  cases,  5 deaths;  diarrhoea, 
chronic,  17  cases  and  77  deaths. 

In  1869,  only  a few  sporadic  cases  of  yellow  fever  occurred.  Fevers  and  bowel  affections 
caused  a comparatively  small  mortality,  and  it  cannot  be  claimed  that  disinfection  prevented  the 
spread  of  the  disease. 

YELLOW  FEVER  OF  1870. 

The  total  deaths  in  the  city  of  New  Orleans  during  1870  wero  7391,  being  considerably  more 
numerous  than  in  the  two  preceding  years.  Smallpox  alone  caused  528  deaths,  while  in  the  pre- 

#“  Annual  Report  of  the  Board  of  Health  to  the  General  Assembly  of  Louisiana,"  Dec.  31st,  1869, 
pp.  8,  9.  t “ Annual  Report  of  the  Board  of  Health,”  Dec.  31st,  1869,  p.  10. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


395 


ceding  year  this  disease  caused  137  deaths  and  varioloid,  4;  total  in  1869,  141.  The  epidemic 
of  smallpox  during  both  years  appears  to  have  been  affected  by  the  temperature;  thus,  in  1869, 
the  monthly  deaths  by  the  disease  were,  January,  3;  February,  1 ; March,  1;  April,  2;  Juno,  5; 
August,  1;  September,  1;  October,  5;  November,  33;  December,  89.  1870,  January,  69;  Feb- 

ruary, 56;  March,  121;  April,  122;  May,  78;  June,  59;  July,  14;  August,  4;  September,  3; 
November,  1;  December,  1.  The  deaths  from  bowel  affections  were,  in  1870,  cholera,  3;  cholera 
infantum,  65;  cholera  morbus,  15;  congestion  of  bowels,  13  ; diarrhoea,  acute,  10;  diarrhoea, 
chronic,  93;  diarrhoea, -62 ; dysentery,  94  ; dysentery,  acute,  15  ; dysentery,  chronic,  75  ; inflam- 
mation of  bowels,  104;  total  disease  of  bowels,  549.  Consumption  caused  757  deaths.  The  deaths 
from  the  various  forms  of  fever  were  as  follows:  Fever,  1;  bilious,  35;  brain,  29;  congestive, 
141;  gastric,  4;  intermittent,  27;  malarial,  52;  nervous,  4;  pernicious,  100 ; puerperal,  17; 
remittent,  51 ; scarlet,  44;  hectic,  5;  typhoid,  80;  typhus,  13 ; yellow,  587.  Total  deaths  by 
fevers,  1189. 

The  number  of  deaths  from  consumption  seems  to  have  increased  during  the  year  1870,  there 
having  occurred  757  deaths  from  that  disease,  against  684  in  1S69,  632  in  1868,  and  671  in  1867. 
The  number  of  deaths  from  measles  during  this  year  was  only  23,  against  217  in  1869;  there 
were  no  deaths  from  this  disease  in  1868.  The  number  of  deaths  from  whooping  cough  in  1870 
was  only  9,  while  in  1869  they  numbered  121. 

The  admissions  into  the  Charity  Hospital  numbered  7S37,  and  the  deaths  1118;  yellow  fever, 

1515  cases,  deaths,  262.  More  than  one-half  the  cases  of  yellow  fever  terminated  fatally  in  the 
Charity  Hospital,  and  nearly  one-half  of  the  total  mortality  from  this  disease  in  New  Orleans 
occurred  within  the  walls  of  the  Charity  Hospital.  The  deaths  caused  by  the  various  forms  of 
fever  in  this  institution  were  as  follows : Typhoid,  17 ; malarial,  60 ; typhus,  1 ; intermittent,  7 ; 
remittent,  6 ; puerperal,  1 ; typho-malarial,  2.  Diarrhoea  and  dysentery  caused  127  deaths,  and 
phthisis  pulmonalis  1S1  deaths. 

During  the  summer  and  autumn  of  1870  the  deaths  from  yellow  fever,  as  reported  by 
the  Board  of  Health,  numbered  587 ; but  it  is  worthy  of  note  that  other  forms  of  fever,  chiefly 
malaria],  caused  602  deaths;  total  from  fevers  in  1870,  1189.  Of  this  number,  241  were  recorded 
as  due  to  pernicious  and  congestive  fevers.  The  first  death  is  said  to  have  occurred  on  the  2d  of 
June.  The  subject,  an  officer  on  the  steamer  “ Agnes,”  had  recently  returned  from  a trip  to 
Honduras,  having  touched  last  at  Port  Cavallo.  He  arrived  May  16th,  and  died  June  2d.  No 
other  cases  of  sickness  occurred  among  the  officers  and  men  of  the  “ Agnes.”  According  to  the 
report  of  the  Board  of  Health,  the  premises,  bedding  and  clothing  were  fumigated  three  times 
with  chlorine,  and  no  case  occurred  in  that  immediate  vicinity  in  the  First  District  during  the 
remainder  of  the  year.  The  next  case  in  the  First  District  was  at  186  Dryades  street,  Septem- 
ber 6th,  an  Italian  from  the  French  Market;  September  7th,  two  cases  at  481  Rampart  street, 
both  Italians;  September  12th,  one  case  on  Girod  street,  near  Camp.  The  deaths  from  yellow 
fever  in  the  First  District  were:  June,  1;  July,  0;  August,  0;  September,  26;  October,  62; 
November,  29;  December  4;  total,  122.  Dr.  Jules  A.  Mathieu,  Sanitary  Inspector  of  the  First 
District,  states  that  “the  premises,  in  each  case  of  yellow  fever,  were  fumigated  from  one  to  three 
times,  whether  the  eases  terminated  by  recovery  or  death,  and  yet  the  local  outbreak  exhibited 
the  usual  epidemic  curve,  increasing  in  September,  reaching  its  maximum  in  October,  declining 
with  the  cold  of  November,  and  disappearing  in  December.  The  measures  instituted  did  not  pre- 
vent the  occurrence  of  122  deaths  in  the  First  District.” 

The  first  case  reported  in  the  Second  District  was  taken  ill  August  14th  and  died  August  19th. 
For  a short  time  the  disease  appeared  not  to  increase;  an  examination  of  the  mortuary  reports 
shows,  however,  that  a number  of  Italians  died  soon  after  in  the  same  neighborhood,  but  that 
the  certificates  state  deaths  to  have  been  caused  by  some  of  the  forms  of  malarial  fever.  Dr. 
White,  the  President  of  the  Board  of  Health,  affirmed  that  these  should  have  been  placed  to  the 
account  of  yellow  fever. 

The  first  case  of  yellow  fever  in  the  Third  District  occurred  at  155  Piety  street,  and  the 
second  at  312  Lafayette  street — both  Italians. 

The  first  case  in  the  Fourth  District  was  on  Ninth  street,  September  30th,  a butcher  from  the 
French  Market,  which  proved  fatal;  the  first  case  in  the  Fifth  District,  September  27th;  the 
first  case  in  the  Sixth  District,  October  4th. 

In  the  Second  District,  the  disease  was  epidemic  only  in  that  portion  included  botween  St. 


396 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Ann  nnd  Barracks  streets  inclusive,  and  the  river  and  Rampart  street.  Of  252  cases  in  the 
Second  District  whose  residences  were  recorded  at  the  office  of  the  Board  of  Health,  only  12  were 
back  of  Rampart  street,  and  only  17  in  the  street  parallel  with  St.  Ann  street  up  to  Canal  street. 
Tho  list  of  residences  is  imperfect,  as  in  the  early  part  of  the  epidemic  the  residences  of  cases 
received  at  tho  Charity  Hospital,  reported  to  the  Board,  were  not  given.  Most  of  the  mortality 
of  the  Charity  Hospital  was  of  sick  received  from  this  district,  as  above  defined.  Another  infected 
part  of  the  city  was  in  tho  vicinity  of  Girod  street.  In  the  district  extending  from  the  river  to 
the  Girod  street  Cemetery,  and  from  Poydras  to  Delord,  62  cases  occurred  out  of  134  reported  in 
tho  whole  First  District. 

A marked  peculiarity  of  the  disease,  in  its  course,  was  the  rapidity  with  which  it  increased  in 
tho  first  five  weeks,  showing  its  tendency  to  become  epidemic,  and  afterward  the  long  period  in 
which  there  was  little  change  in  tho  weekly  mortality  from  it.  The  weather,  for  a month  pre- 
vious to  the  appearance  of  yellow  fever  in  1870,  had  been  very  warm  and  sultry,  with  daily  rains, 
and  close,  unpleasant  nights.  After  the  disease  had  made  some  progress,  the  weather  became 
exceedingly  dry,  and  at  the  period  when  the  disease  was  at  its  maximum,  the  weather  became 
quite  cool,  steady  north  winds  prevailing,  with  hot  sun  and  increasing  dryness.  There  was  no 
rain  for  six  weeks.  It  has  been  urged  that  the  unusual  course  of  the  disease  was  due  mainly  to 
these  climatic  causes. 

According  to  the  published  statement  of  the  President,  all  cases  that  came  to  the  knowledge 
of  the  Board  of  Health  were  treated  by  the  free  use  of  such  disinfectants  as  chlorine,  sulphurous 
acid,  carbolic  acid  and  lime. 

Dr.  F.  B.  Albers,*  who  had  charge  of  the  Second  District,  in  which  399  deaths  occurred  out 
of  a total  in  the  entire  city  of  587,  says: — 

“ In  every  instance,  when  a case  of  yellow  fever  took  place,  the  house  where  it  occurred,  also 
its  immediate  neighborhood  and  premises,  were  disinfected,  by  setting  free  chlorine  and  sulphur- 
ous acid  gas  in  the  rooms  where  death  had  taken  place.  The  gutters  of  the  yard  were  sprinkled 
freely  with  copperas  and  carbolic  acid,  and  the  carbolo-hydrochloride  of  iron  used  as  a permanent 
disinfectant  about  the  sinks,  privies  and  vaults.  The  streets  and  gutters  of  that  portion  of  the 
district  where  the  disease  prevailed  were  also  disinfected,  September  14th,  by  distributing  five 
barrels  of  lime  throughout  that  particular  locality,  and  following  it  up  on  the  15th  by  distributing 
two  barrels  of  carbolic  acid,  containing  100  gallons,  on  the  same  ground.  As  this  appeared  to 
have  the  desired  effect — to  check  the  disease  from  spreading — and  the  quantity  being  barely  suffi- 
cient to  give  the  infected  locality  a small  quantity  all  around,  200  gallons  more  were  applied  on 
the  19th,  200  on  the  20th,  and  200  on  the  22d.  As  it  evidently,”  continues  Dr.  Albers,  “ appeared 
to  check  the  disease  at  the  time  and  arrest  its  progress,  the  disinfection  by  carbolic  acid  was 
repeated  on  the  24th,  26th  and  27th.  The  duty  was  invariably  performed  at  night,  to  enable  the 
antiseptic  properties  of  the  carbolic  acid  to  exert  its  full  influence  before  the  heat  of  the  sun 
should  evaporate  it.” 

It  is  evident,  from  the  preceding  statement,  that  Dr.  Albers  used  about  1300  gallons  of  car- 
bolic acid  in  this  infected  district  in  the  course  of  twelve  days,  and  without  arresting  the  disease 
in  the  month  of  September,  or  in  tho  succeeding  months  of  October  and  November. 

According  to  his  own  statement,  210  deaths  occurred  from  yellow  fever  in  this  “disinfected," 
district  in  September,  165  in  October,  and  20  in  November. 

How  much  carbolic  acid  was  used  in  tho  month  of  October  wo  are  not  informed,  but  it  is  evi- 
dent that  the  disease,  as  usual,  declined  as  the  season  progressed,  and  the  weather  became  drier 
and  cooler.  And  it  is  still  further  worthy  of  note  that  the  highest  mortality  in  the  Second  Dis- 
trict occurred  on  the  27th  of  September,  viz.,  22  deaths,  immediately  after  the  most  liberal  and 
energetic  use  of  the  carbolic  acid. 

In  tho  city,  generally,  the  monthly  mortality  by  yellow  fever  was  as  follows : August,  3 ; Sep- 
tember, 231;  October,  242;  November,  106;  December,  5;  total,  587.  In  other  words,  the 
heaviest  mortality  occurred  in  the  month  of  October,  after  tho  thorough  installation  of  tho  “car- 
bolic acid  disinfection.” 


* “ Annual  Report  of  the  Board  of  Health  to  the  General  Assembly  of  Louisiana,”  December  31st, 
1870,  pp.  39-45. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  397 


TABLE  SHOWING  THE  NATIVITIES  OF  PERSONS  WHO  DIED  OF  YELLOW  FEVER 

DURING  THE  SEASON  OF  1S70. 


Countries. 

Week  ending 
Augu  t 28th. 

September  4th. 

September  11th. 

September  18th. 

September  25th. 

October  2d. 

October  9th. 

October  16th. 

Octoler  23d. 

October  30th. 

November  6th. 

November  13th. 

November  20lh. 

November  27th. 

December  4ih. 

Total. 

Italy 

16 

30 

25 

20 

7 

5 

2 

4 

3 

1 

113 

France 

1 

1 

7 

18 

18 

17 

4 

5 

4 

5 

4 

1 

1 

86 

Germany 

1 

1 

1 

2 

10 

18 

26 

22 

15 

11 

7 

8 

3 

1 

3 

129 

United  States 

3 

5 

9 

11 

13 

6 

12 

11 

7 

3 

8 

84 

Ireland 

i 

1 

1 

2 

8 

5 

6 

4 

10 

7 

2 

1 

48 

Switzerland 

1 

1 

5 

2 

3 

3 

2 

1 

18 

England 

1 

3 

i 

1 

2 

5 

i 

3 

2 

2 

21 

British  America 

3 

1 

o 

1 

1 

8 

Wales 

2 

2 

l 

1 

1 

i 

8 

Scotland 

1 

2 

2 

1 

2 

1 

9 

Other  Countries 

5 

6 

8 

9 

5 

12 

i 

4 

5 

3 

i 

59 

Total 

3 

1 

19 

52 

70 

89 

84 

60 

54 

44 

38 

38 

16 

14 

5 

587 

Note.— Dr.  Del  Orto  reports,  as  the  result  of  his  investigation,  the  death  of  one  hundred  and 
twenty-eight  natives  of  Italy  by  yellow  fever. 

Dr.  Albers  says  that  the  effect  of  his  plan  of  disinfection  “ where  it  was  thoroughly  tried,  has 
certainly  been  very  satisfactory,  and  if  properly  brought  into  effect  previous  to  the  appearance  of 
any  disease,  will  probably  prevent  it  entirely.  I give  the  following  instance  as  a proof  of  the 
value  of  the  mode  of  disinfection  practiced : — 

“ No.  230  Chartres  street  is  a tenement  house,  running  through  to  Old  Line  street,  containing 
thirty  rooms,  and  it  was  occupied,  when  the  fever  made  its  appearance  there,  by  thirty  families, 
consisting  of  183  persons,  all  natives  of  Italy ; of  these  44  took  the  fever,  14  died,  26  recovered, 
4 taken  to  the  hospital.  Of  the  remaining  139  people  that  did  not  take  the  fever,  43  were  here 
less  than  one  year,  32  less  than  two  years,  17  less  than  three  years,  47  over  three  years.”  Dr. 

1 Albers  estimates  that  92  of  the  139  people  were  unacclimated.  “ After  the  process  of  fumiga- 
tion and  disinfection  only  two  more  persons  were  taken  sick.” 

Dr.  Albers  held  that  the  yellow  fever  which  prevailed  during  the  months  of  September 
and  October  was  of  domestic  origin,  and  due  to  the  crowded  and  filthy  condition  of  the  city,  and 

! especially  in  the  First  and  Second  Districts,  which  are  the  largest,  most  populous  and  most 
actively  engaged  in  commercial  pursuits.  It  is,  however,  established  that  the  first  case,  that  of 
the  officer  of  the  steamer  “Agnes,”  was  connected  with  the  shipping;  and  Dr.  Albers  himself 
: records  the  fact  that  Robert  Bell  Craig,  who  left  Havana  on  the  17th  of  August,  arrived  at 

Mobile  on  the  20th,  came  to  New  Orleans  on  the  21st,  remained  over  night  at  a boarding  house, 

| corner  of  Old  Line  and  Tolouse  streets,  went  to  the  Charity  Hospital  22d,  and  died  of  black  vomit 
on  the  26th.  Dr.  Albers  says  that  the  character  of  the  fever  was  of  a very  malignant  type,  and 
the  mortality  was  about  33  per  cent. 

With  reference  to  the  contagious  nature  of  the  yellow  fever  of  1870,  the  President  of  the 
Board  of  Health  says  : “ In  the  Charity  Hospital,  this  year,  the  disease  seemed  to  spread  by  con- 
",  tiguity  from  those  sick  of  yellow  fever  to  thoso  ill  of  other  diseases — something  not  known  to 
have  occurred  previously.” 

Dr.  Albers  says  : “ The  contagiousness  of  the  fever  has  been  remarkable  when  no  disinfection 
■ was  resorted  to,  as  for  instance,  at  the  Louisiana  Bakery,  where,  as  men  employed  there  were 
i taken  sick  and  left  to  go  to  their  friends  or  to  hospitals,  now  men  were  then  employed  and  put 
into  the  same  beds  and  rooms  that  the  others  had  vacated,  and  invariably  became  sick  soon  after. 

' The  same  reckless  disregard  of  all  moral  obligations  and  duties  to  others,  and  particularly  to 
s strangers,  has  furnished  almost  all  the  yellow  fever  patients  of  the  Second  District,  which  district 
' supplies  the  hospital  with  fresh  cases,  derived  invariably  from  tho  various  boarding  houses,  prin- 
| cipally  in  the  neighborhood  of  the  levee,  where  the  inmates  had  contracted  the  disease  previously. 


398 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


These  fresh  cases  of  yellow  fever  were  new  comers,  put  into  the  same  rooms  and  beds  lately  occu- 
pied by  their  sick  predecessors.” 

“To  illustrate  the  contagiousness  of  the  fever,  I can  refer  to  several  instances  that  came  under 
my  observation.  There  are  three  establishments  up  town  which  are  in  close  proximity  to  each 
other.  One  of  them  is  a large  corn  mill  and  the  other  two  are  bakeries.  They  employ  a number 
of  men  of  various  nationalities,  who  sleep,  and  generally  also  board,  on  the  premises;  they  were 
all  there  attacked  by  the  fever  about  the  1st  of  October.  Neither  of  the  establishments  was  dis- 
infected at  all,  as  the  proprietors  of  them  positively  refused  to  have  it  done,  and  the  fever  con- 
tinued to  linger  in  these  places  and  attack  new  comers,  as  they  were  employed  to  take  the  places 
of  their  predecessors  who  had  been  carried  off  with  the  fever,  until  the  22d  of  November,  when 
the  last  of  them  died,  and  the  cold  weather  effectually  put  a stop  to  any  further  infection. 

“ Another  instance  came  also  to  my  personal  knowledge  ; it  was  that  of  a lady,  up  town,  who 
has  some  reputation  as  a ' doctoress,’  and  took  several  gentlemen  into  her  house  to  ‘ nurse’  through 
the  yellow  fever.  The  first  cases  that  occupied  her  rooms  and  beds  yielded  readily  to  treatment 
and  were  soon  convalescent.  When  they  went  away  and  their  places  were  taken  by  others, 
although  they  presented  the  same  mild  type  of  the  fever  as  the  former  ones  when  they  arrived, 
they  would  soon  assume  a more  severe  type,  and  almost  invariably  prove  fatal.  And  as  no 
fumigation  or  disinfection  was  resorted  to,  it  is,  without  doubt,  to  be  attributed  to  the  influence 
of  the  poison  that  they  imbibed  from  the  immediate  surroundings  to  which  they  were  exposed, 
in  addition  to  that  already  existing  in  these  sections.”* 

Dr.  Alfred  Perry  states  that  the  yellow  fever  made  its  appearance  in  the  Fourth  District  “in 
the  latter  part  of  September;  six  weeks  after  its  first  appearance  in  the  city,  only  25  cases  having 
been  reported  in  the  district.  Four  among  the  first  cases  gave  clear  evidence  of  having  been 
communicated  by  infection.” 

It  will  be  observed  from  the  preceding  record  that  only  88  natives  of  the  United  States  died 
of  yellow  fever  in  1870,  out  of  a total  of  587  deaths  from  this  disease.  It  is  probable  that  but  very 
few  of  these  eighty-eight  natives  of  the  United  States  had  been  born  in  New  Orleans.  On  the 
other  hand,  the  total  number  of  deaths  during  1870  (7391),  more  than  one-half,  or  4753,  were 
natives  of  the  United  States;  99  of  England,  352  of  France,  518  of  Germany,  551  of  Ireland,  and 
199  of  Italy.  If  we  accept  the  estimate  of  Dr.  Del.  Orto,  of  the  199  deaths  among  Italians,  128 
were  caused  by  yellow  fever,  leaving  only  71  deaths  from  all  other  causes,  the  various  forms  of 
malarial  fevers  included.  Among  the  Italians  1 death  in  1.55  deaths  from  all  causes  were  due  to 
yellow  fever;  among  the  English,  1 death  in  4.19;  among  the  natives  of  France,  1 death  in  4.09; 
among  the  Germans,  l death  in  4.01;  among  the  Irish,  1 death  in  11.48;  among  the  natives  of 
Switzerland  (38  deaths  from  all  causes)  1 death  in  2.11;  while  among  the  natives  of  New  Orleans 
and  of  Louisiana,  and  of  all  other  parts  of  the  United  States,  only  1 death  from  yellow  fever  in 
54.01  deaths  from  all  causes.  No  data  exists  for  the  determination  of  the  number  of  cases  of  yel- 
low fever  occurring  in  the  city,  nor  of  the  relations  of  these  cases  to  the  different  nationalities. 
In  the  Charity  Hospital  alone,  as  we  have  seen,  515  cases  (of  which  about  one-half  in  262  died), 
of  yellow  fever  were  admitted;  and  as  the  mortality  was  much  heavier  than  in  private  practice, 
it  would  be  fair  to  estimate  the  deaths  as  about  one  in  every  four  cases  of  yellow  fever,  which 
would  give  587  X 4 = 2348  cases  of  yellow  fever  in  the  entire  city  of  New  Orleans  during  the 
epidemic  of  1870,  when  carbolic  acid  and  other  agents  were  vigorously  used  to  arrest  and  limit 
the  disease. 

It  is  evident  from  the  preceding  facts  that  the  natives  of  the  United  States  who  have 
resided  in  New  Orleans  for  various  periods  of  time  suffered  to  a limited  extent  from  yellow  fever; 
while  the  disease  spread  among  the  Italians,  French,  Germans  and  Irish  and  natives  of  Switzer- 
land, occasioning  the  vast  proportion  of  deaths  among  the  unacclimated  foreigners. 

The  conclusion  is  justified,  therefore,  that  the  absence  or  scarcity  of  material  among  the  resi- 
dent and  native  population,  black  and  white,  which  had  been  recently  subjected  only  three  years 
before,  in  1867,  to  a sweeping  epidemic,  was  the  cause  of  the  limited  nature  of  the  epidemic 
yellow  fever  of  1870,  rather  than  the  action  of  the  disinfectants  used  by  the  Board  of  Health. 


* “ Annual  Report  of  the  Board  of  Health  to  the  General  Assembly  of  Louisiana,”  December  31st,  1870, 
pp.  9-12,  30,  39,  44,  52,  74,  77. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  399 


YELLOW  FEVER,  1871. 

The  total  deaths  from  all  causes  in  1871  numbered  6059,  of  which  the  forms  of  fever  caused, 
respectively,  fever,  2;  bilious,  25;  catarrhal,  1;  congestivo,  102;  gastric,  1;  hectic,  3;  hemor- 
rhagic, 26;  intermittent,  26;  malarial,  94;  nervous,  2;  pernicious,  61  ; puerperal,  14;  remittent, 
39;  scarlet,  5;  typhoid,  71;  typhus,  4;  yellow,  54;  total  deaths  by  fevers,  530.  Smallpox  caused 
only  two  deaths;  measles,  12 ; while  meningitis  (cerebro-spinal  chiefly)  caused  128  deaths;  cholera, 
6;  cholera  infantum,  84;  cholera  morbus,  18;  diarrhoea,  1S5;  dysentery,  155;  inflammation  of 
bowels,  106;  total  bowel  affections,  544.  Consumption,  780 ; infantile  convulsions,  200. 

In  the  Charity  Hospital,  29  cases  of  yellow  fever  were  admitted,  of  which  20  died.  1884 
cases  of  intermittent  and  malarial  fever,  53  deaths;  3 cases  “typho-malarial,”  3 deaths;  19 
typhoid,  14  deaths;  72  remittent,  5 deaths;  16  pernicious,  10  deaths;  diarrhoea  and  dysentery, 
412  cases,  169  deaths;  phthisis  pulmonalis,  178  cases,  170  deaths.  Total  admissions,  all  diseases, 
6651;  total  deaths,  all  causes,  891. 

The  first  case  of  yellow  fever  reported  died  in  the  Charity  Hospital,  August  4th;  the  second 
case,  August  20th,  after  five  days’  illness;  third,  September  5th,  after  six  days’  illness.  In  July, 
1 case,  1 death;  August,  2 cases,  2 deaths;  September,  37  cases,  9 deaths;  October,  53  cases,  22 
deaths;  November,  33  eases,  19  deaths;  December,  2 cases,  2 deaths.  Total  cases  reported,  114; 
total  deaths,  54 ; the  enormous  mortality  being  reached  among  these  sporadic  and  “ disinfected,” 
cases  of  47.3  per  cent.,  or  one  death  in  2.1  eases.  The  disease  was  chiefly  confined  to  the  Fourth 
District,  and  it  has  been  claimed  that  its  limited  spread  was  mainly  due  to  the  liberal  use  of 
carbolic  acid.  Sporadic  cases,  however,  appeared  in  various  sections  of  the  city,  and  the  disease, 
as  in  numberless  other  years,  in  this  and  other  Southern  cities,  in  which  neither  carbolic  acid 
nor  any  other  disinfectants  were  used,  showed  no  disposition  to  spread.  The  fact  that  in  certain 
Southern  towns  the  disease  exhibited  a tendency  to  spread  did  not  indicate  anything  more  than 
what  has  often  occurred  before  in  the  history  of  yellow  fever  on  the  Atlantic  and  Gulf  coasts. 

The  following  are  the  facts  with  reference  to  the  yellow  fever  of  1871,  as  officially  reported  by 
Dr.  C.  B.  White,  President  of  the  Board  of  Health,  and  the  Secretary  and  Sanitary  Inspectors  : — 

Case  i. — On  the  4th  of  August,  Charles  Collingberg,  of  Iowa,  was  taken  to  the  Charity  Hos- 
pital, where  he  died  the  same  night  of  yellow  fever  with  black  vomit.* *' 

Investigation  of  the  case  furnished  the  following  facts:  He  came  to  the  city  by  way  of  the 
river,  as  flatboatman,  about  four  weeks  previously ; was  homeless,  without  occupation ; slept  about 
the  elevator  wharf,  and  drank  all  the  liquor  ho  could  pay  for  or  get  upon  credit.  The  night  before 
being  taken  to  the  hospital  he  was  received  upon  the  floating  elevator,  as  an  act  of  charity,  and 
given  sleeping  quarters.  For  not  less  than  four  nights  previous  he  had  been  sleeping  about  the 
bark  “ Mary  Pratt,”  from  Cienfuegos,  discharging  sugar  into  the  elevator  warehouse.  The  “ Mary 
Pratt”  brought  a clean  bill  of  health  to  the  quarantine  station,  and  had  no  sickness  on  board. 
After  her  arrival  in  the  city,  the  crew  were  discharged,  the  captain  took  rooms  in  the  city,  and 
only  the  mate  was  left  on  board.  At  this  date  her  hatches  were  opened,  and  while  discharging 
cargo  Collingberg  slept  on  board,  and  was  taken  sick.  The  stevedore’s  gang  which  discharged 
the  cargo  was  found  to  be  composed  of  men  long  residents  of  the  city  and  fully  acclimated. 
These  facts,  and  the  habits  and  condition  of  Collingberg,  probably  account  for  his  being  the  only 
sufferer  from  this  supposed  infectious  vessel. 

Disinfection  by  sulphurous  acid  and  chlorine  was  practiced  on  the  floating  elevator  and  in  the 
elevator  warehouse  for  several  days,  and  the  ship  sent  to  the  quarantine  ground,  to  be  disinfected 
at  the  discretion  of  the  resident  physician.  The  crew  were  followed  to  their  boarding-house,  and 
their  effects  thoroughly  fumigated  and  aired. 

— 

* I made  a careful  chemical  and  microscopical  examination  of  the  liver,  heart,  kidneys,  stomach  and 
black  vomit  taken  from  the  body  of  Charles  Collingberg,  and  the  general  results  were  as  follows:  Stomach 
of  a deep  red  and  purplish  color,  with  softened  and  eroded  mucous  membrane.  Black  vomit  contained 
altered  blood  corpuscles,  mucous  cells,  broken  capillaries,  urea  and  ammonia.  The  pericardium  of  the 
heart  was  highly  injected  with  blood.  Muscular  structures  of  heart  of  yellow  color,  softened,  loaded  with 
oil  globules  and  granular  matter,  and  the  transverse  striae  were  indistinct,  and  in  many  fibrilhe  obliter- 
ated. The  liver  presented  the  usual  yellow  color  and  contained  much  oil,  as  in  well-marked  yellow 
fever.  Kidneys  of  yellow  color,  with  granular,  matted  and  detached  excretory  cells  filling  the  tubuli 
uriniferi.  A small  quantity  of  urine  obtained  from  his  bladder  contained  albumen  and  urinary  casts. 

Joseph  Jones,  m.d. 


400 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


On  August  10th  the  “Mary  Pratt”  was  sent  up  to  the  quarantine  station,  and  on  August  13th 
was  laid  to  the  wharf,  foot  of  Terpsichore  street.  August  23d,  George  M.  Mousse  was  employed 
as  steward,  and  began  work  on  board  the  “ Mary  Pratt,”  clearing  up  her  cabin,  reported  to  be  in 
a very  filthy  condition,  and  was  taken  sick  with  yellow  fever  on  the  29th ; was  removed  to  the 
Hotel  Dieu  September  4th,  and  died  September  5th. 

The  vessel  was  again  taken  in  charge  by  the  Sanitary  Inspector  of  the  First  District,  thor- 
oughly fumigated  for  a number  of  days,  and  no  unacclimated  persons  allowed  on  board. 

John  Hoch,  a tailor  by  trade,  working  and  residing  at  433  Tchoupitoulas  street,  between  Pwobin 
and  Race  streets,  first  and  second  streets  above  Terpsichore  street,  at  the  foot  of  which  lay  the 
“Mary  Pratt;  ” had  been  in  the  city  six  months;  confined  himself  entirely  to  the  house  and  shop, 
save  at  evening,  at  which  time,  the  family  state,  he  always  went  down  to  the  levee  to  walk  about. 
He  was  seized  with  yellow  fever  September  4th,  and  died. 

Mr.  John  M.  Rawlins,  Custom  House  Inspector,  was  attacked  with  yellow  fever  August  15th, 
and  died  August  20th,  at  his  residence,  118  Washington  street.  Mr.  Rawlins  was  from  Alabama, 
and  had  been  a resident  of  the  city  ten  months.  He  left  the  city,  on  duty  for  the  Passes,  July 
29th;  took  official  charge  of  the  brig  “Hope”  August  11th,  then  eleven  days  from  Havana,  with 
sickness  on  board.  The  “ Hope  ” was  detained  at  the  quarantine  station  two  days ; hatches  opened, 
and  enough  of  the  sugar  broken  into  to  enable  thorough  fumigation  to  be  effected  of  both  cargo 
and  bold.  The  hammock  of  Mr.  Rawlins  was  swung  near  the  opened  hatches,  and,  although 
warned  by  the  physician  as  porhaps  exposing  himself  to  disease  by  this  proximity,  he  expressed 
his  entire  fearlessness  as  to  the  danger,  and  remained  in  the  position  before  mentioned.  Less 
than  forty-eight  hours  after  his  arrival  in  the  city,  and  four  days  after  the  arrival  at  the  quaran- 
tine station  and  opening  of  the  ship’s  hatches,  he  was  taken  ill.  The  officers  and  crew  of  the 
“Hope”  were  all  acclimated;  her  cargo  went  up  the  river  immediately,  and  within  a very  few 
days  she  was  again  at  sea. 

Hon.  E.  W.  Pierce,  a member  of  the  Board  of  Health,  was  taken  ill  of  yellow  fever  at  his 
residence,  No.  136  Fourth  street,  September  7th,  and  died  on  the  13th.  The  residence  of  Hr. 
Pierce  was  distant  about  280  feet  from  the  house  in  which  Mr.  Rawlins  died,  and  in  a direction  a 
little  to  the  east  of  north,  diagonally  across  the  block  of  buildings.  The  residence  of  Mr.  David 
Rosenberg,  No.  736  Magazine  street,  who  was  attacked  with  yellow  fever  on  the  9th  of  Septem- 
ber, and  died,  was  in  the  same  lino  of  direction  in  the  Fourth  District,  diagonally  across  another 
block.  The  prevailing  direction  of  the  wind  in  July  and  August  is  from  south  to  north.  Between 
the  residences  of  Mr.  Rawlins  and  Mr.  Pierce  intervened  a cottage,  but  from  the  gallery  of  the 
second  story  of  the  house  of  Mr.  Pierce  was  a direct  and  full  view,  over  the  cottage,  of  the  house 
in  which  Mr.  Rawlins  died.  Just  after  the  death  of  Mr.  Pierce,  it  was  ascertained  that  two 
unacclimated  children  had  been  sick  with  fever,  and  a few  days  later  another  child  was  taken 
ill  in  a similar  manner,  and  the  disease  pronounced  yellow  fever.  It  is  probable  that  the  first  two 
cases  in  the  cottage  were  yellow  fever,  and  formed  the  connecting  links  between  the  cases  of  Mr. 
Rawlins  and  Mr.  Pierce.  Information  of  the  occurrence  of  the  case  of  Mr.  Rawlins  did  not  reach 
the  Board  of  Health  until  twenty  hours  after  his  death,  and  measures  of  disinfection  were  not 
put  in  operation  for  some  hours  later. 

Cases  rapidly  increased  in  the  Fourth  District,  and  from  the  time  of  the  death  of  Mr.  David 
Rosenberg,  on  the  9th  of  September,  thirty-five  cases  were  reported  to  the  Board  of  Health,  up  to 
the  30th  of  the  month.  That  other  cases  occurred,  which  were  never  reported  to  the  Board  of 
Health,  is  evident  from  the  fact  that  the  case  of  Mr.  Rawlins  was  not  reported  until  twenty  hours 
after  his  death,  and  the  two  children  in  the  cottage  “ were  not  reported  as  sick  nor  submitted  to 
examination,  and  they  do  not  appear  in”  the  official  list  of  cases.  We  have  no  data  by  which 
to  estimate  the  “ unreported”  cases. 

On  the  13th  of  September  Dr.  D.  B.  Albers,  Sanitary  Inspector  of  the  Second  District — where 
occurred  the  local  epidemic  of  1870 — was  placed  in  charge  of  tbo  infected  district. 

After  stating  that  the  yellow  fever  of  1871  was  carried  to  the  Fourth  District  by  the  custom- 
house officer,  J.  M.  Rawlins,  who  contracted  it  on  the  brig  “ Hope,”  eleven  days  from  Havana, 
Dr.  Albers  says: — 

“Thoro  were  sixteen  cases  under  treatment  at  tho  time  I took  ehargo  of  the  district;  nine 
more  were  taken  subsequently,  up  to  tho  28th;  tho  last  ono  died  on  tho  23d.  No  more  cases 
occurred  up  to  the  4th  of  October,  when  I withdrew  from  tho  district,  as  tho  threatened  epidemic 


MEDICINE. 

SECTION  XV — PUBLIC  AND  INTERNATIONAL  H.YGIENE.  401 

had  been  prevented,  and  my  presence  was  imperatively  necessary  in  the  Second  District.  When 
I took  charge  of  the  infected  district,  the  fever  prevailed  in  that  portion  of  it  bounded  by  Chip- 
pewa, Magazine,  Sixth  and  Third  streets.  It  did  not  spread  beyond  these  limits,  owing  to  tho 
energetic  measures  taken  to  prevent  it.  The  means  adopted  to  check  tho  course  of  the  yellow 
fever  were  an  energetic,  thorough  and  liberal  distribution  of  carbolic  acid  over  tho  entire  vicinity 
of  the  infected  district,  extending  its  application  as  far  as  the  influence  of  the  poison  could  have 
prevailed.  In  this  way  there  were  consumed,  between  Wednesday,  the  13th,  and  Saturday,  the 
16th,  10,000  gallons  of  carbolic  acid,  and  it  may  be  said  that  the  entire  vicinity  was  soaked 
in  it. 

“ It  was  freely  applied  to  the  filthy  streets,  unpaved  yards,  alleys,  stagnant  gutters  and  ditches 
by  which  all  of  tho  streets  and  many  of  the  houses  were  surrounded,  as  well  as  to  manure  heaps, 
collections  of  refuse  and  other  nuisances  which  abounded  in  that  neighborhood.  Carbolic  acid 
was  chosen  for  this  purpose  as  being  the  best  disinfectant  known,  as  it  coagulates  all  albumen, 
and  is  certain  to  destroy  all  the  lower  forms  of  life.  It  volatilizes  easily  and  freely,  and  thus 
attacks  the  hidden  germs  of  disease  that  float  in  the  atmosphere. 

“This  process  of  disinfection  was  repeated  daily,  and  the  atmosphere  became  highly  charged 
with  the  vapor  of  the  acid,  which  found  its  way  into  the  dwellings  of  the  sick  and  healthy  alike. 
Many  persons  fancied  at  first  that  the  smell  produced  headache,  but  the  most  of  them  soon  became 
convinced  of  their  error,  and  as  these  are  persons  who  dislike  the  smell  and  complain  of  nausea 
when  exposed  to  it,  so  would  these  persons  be  similarly  affected  by  any  unusual  smell,  while  they 
can  bear  patiently  with  the  most  loathsome  smells  because  they  are  familiar  with  them. 

“ Notwithstanding  this,  it  cannot  be  denied  that  the  Sanitary  Inspector  engaged  in  its  distribu- 
tion was  the  most  unpopular  man  in  the  neighborhood  at  that  time,  but  the  ‘end  justifies  the 
means,’  in  this  case  at  least,  and  the  result  has  been  that  the  disease  was  cheeked  in  its  onward 
course,  and  a malignant  and  wide-spread  epidemic  was  prevented.  Not  a single  case  occurred 
beyond  the  limits  where  it  was  raging  on  the  13th.  In  the  course  of  a month,  a few  isolated  cases 
made  their  appearance  again,  and  continued  to  do  so  until  frost,  which  coincides  with  the  remark 
before  made,  that  minute  contagious  particles  will  escape  destruction,  propagate  again,  and  when 
in  sufficient  force  make  themselves  felt.  The  importance,  therefore,  of  continuing  the  application 
of  disinfectants  every  three  or  four  days  during  the  season  favorable  to  its  development  is  evident. 
In  no  instance  has  a second  case  of  fever  occurred  in  any  house  where  this  course  was  carried  out, 
but  when  it  was  objected  to  and  persistently  jjrohibited  by  heads  of  families,  several  members  of 
the  household  took  the  fever  in  succession. 

“ Whenever  a death  occurred  from  the  fever,  the  house  was,  in  every  instance,  thoroughly  dis- 
infected by  fumigating  the  bedrooms,  bed  clothes  and  body  clothes,  alternately,  with  sulphurous 
acid  and  chlorine,  during  several  days  in  succession ; and  the  principal  hotbeds  of  the  fever,  as, 
for  instance,  in  Fourth,  Fifth  and  Magazine  streets,  which  were  entirely  deserted  by  their  occu- 
pants and  in  charge  of  the  Sanitary  Police,  were  daily  disinfected,  fumigated  and  deodorized  from 
their  very  foundation  up  to  the  roof,  for  several  weeks.” 

Dr.  Albers  thus  states  his  theory  of  yellow  fever,  upon  which  he  based  the  system  of  disinfec- 
tion, which  was  similar  to,  but  more  thorough  than,  that  inaugurated  in  1867,  by  Dr.  Smith,  Presi- 
dent of  the  Board  of  Health. 

“ The  yellow  fever  germ,  or  poison,  is  probably  not  generated  in  the  human  system,  nor  trans- 
I mitted  from  one  person  to  another  in  any  way.  (In  those  eases  which  seem  to  arise  by  personal 
contagion  the  poison  is  without  doubt  transmitted  by  the  clothing.) 

“ It  is  an  organic  poison,  the  resultant  of  the  decomposition  of  the  exhalations  and  secretions  of 
the  human  body,  accumulated  and  confined  in  ill-ventilated  habitations,  brought  in  contact  with  the 
effluvia  of  the  public  filth  of  cities  and  acted  on  by  a constantly  elevated  temperature  above  80°  F., 
I for  two  or  three  months  in  succession. 

“This  poison  is  taken  into  the  system  after  the  manner  of  marsh  malarial  poison  (or terrestrial 
emanations),  which  is  strictly  endemic,  of  local  origin,  not  contagious  and  not  portable. 

“The  yellow  fever  poison,  however,  is  portable,  adheres  to  fomites,  and  can  be  carried  in  ves- 
i sels,  trunks,  etc.,  from  one  point  to  another,  and  thus  be  propagated,  and  bears  transportation  to 
u long  distances,  without  losing  its  power  of  reproduction  when  it  meets  with  favorable  conditions, 
among  which  those  of  a high  temperature  is  essential.  It  consists,  doubtless,  of  some  form  of 
■i  microscopic  life,  occupying  that  debatable  ground  between  the  animal  and  vegetable  kingdom,  but 
Vol.IV-26 


402 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


capable  of  rapid  self-propagation,  lying  on  and  moving  along  the  ground,  not  influenced  greatly 
by  winds,  or  it  would  spread  far  more  rapidly,  and  is,  like  most  other  minute  and  tender  germs, 
checked  by  a freezing  temperature,  which,  though  it  does  not  perhaps  kill  the  germ  or  seed,  is 
sufficient  to  suspend  its  action  for  a season,  to  be  called  into  action  again,  at  a later  period,  by 
particular  meteorological  conditions  or  other  suitable  circumstances.”  * 

Holding  the  theory  that  the  germ  of  yellow  fever  might  survive  through  the  winter  and  again 
become  active  during  the  summer  and  fall,  Dr.  Albers  endeavored  to  prevent  the  yellow  fever  from 
making  its  appearance  in  the  Second  District,  where  it  had  prevailed  in  1870,  by  enforcing  the 
strictest  cleanliness  in  that  portion  of  the  city  that  has  always  been  notorious  for  its  unhealthi- 
ness, and  where  the  yellow  fever  has  not  unfrequently  first  made  its  appearance  in  former  years. 
As,  for  instance,  in  the  neighborhood  of  the  French  Market,  where  common  lodging  houses 
abound  and  people  of  the  lowest  condition  of  life  congregate  in  large  numbers  and  in  unrestricted 
license  and  confusion,  no  decaying  substances  of  any  nature  were  allowed  to  remain  on  any  of  the 
premises. 

“ The  water  closets  of  all  suspected  places  were  deodorized  and  disinfected  with  carbolic  acid, 
and  a saturated  solution  of  carbonate  of  iron  in  strong  hydrochloric  acid  every  week  throughout 
the  entire  sickly  season. 

“ Another  one  of  the  most  important  duties  was  to  visit  all  the  suspected  places  rendered  suspi- 
cious by  the  presence  of  fever  in  them  last  year,  every  day,  and  frequently  twice  a day,  to  ascer- 
tain if  there  was  any  one  sick  in  any  of  these  houses,  and  the  landlords  of  all  the  lodging  and 
boarding  houses  were  particularly  requested  to  assist,  to  the  best  of  their  ability,  in  ferreting 
out  any  case  of  sickness  that  occurred  on  their  premises,  on  which  measure  they  all  coincided,  and 
gave  frequent  information  on  that  point. 

“ During  the  latter  part  of  July,  1871,  a party  of  five  men,  all  natives  of  Malta,  and  between 
twenty-four  and  twenty-eight  years  of  age,  less  than  one  year  in  the  United  States,  arrived  here 
from  Galveston,  where  they  had  resided  a short  time.  These  men  rented  a room  on  the  ground 
floor  of  the  courtyard  connected  with  the  building,  No.  239J  Decatur  street,  and  which  opens  on 
the  street  through  an  alley  69  feet  long  and  8 feet  wide,  with  a double  iron  gate  at  the  entrance. 
This  courtyard  forms  a hollow  square,  62  by  36  feet,  built  all  around  its  four  sides,  two  stories 
high,  and  occupied  by  16  families,  comprising  60  persons,  all  natives  of  Italy,  Sicily  and  Malta, 
and  totally  unacclimated,  not  one  of  them  having  been  in  the  country  over  three  years,  and  the 
majority  less  than  one  year.  Their  water  supply  is  river  water  and  they  have  no  cistern.  The 
room  that  these  five  men  occupied  is  14£  feet  wide,  15J  feet  long  and  11  feet  high,  with  a door  ( 
9 feet  high,  4 feet  wide,  and  a window  opening  on  the  courtyard,  which  never  admits  any  sun- 
light, and  almost  no  ventilation. 

“Soon  after  their  arrival  they  were  joined  by  two  more  of  their  countrymen,  from  Galveston, 
and  all  seven  occupied  this  room.  Their  occupation  was  to  peddle  onions,  lemons  and  berries. 
The  boxes  in  which  they  bought  the  latter  served  them  as  bedsteads,  which,  with  a few  mattresses, 
a table  and  a few  cooking  utensils,  constituted  their  only  incumbrances. 

“ Two  of  these  men  were  taken  with  yellow  fever  almost  simultaneously  on  the  24th  of  October. 
As  soon  as  I obtained  information  that  they  were  sick,  I had  them  taken  to  the  hospital,  where 
they  soon  after  died.  I had  the  others  removed  to  another  room,  at  the  time  unoccupied,  in  the 
same  yard,  of  the  same  dimensions  as  the  former,  allowing  them  to  take  nothing  out  with  them 
but  the  clothes  they  had  on  at  the  time,  while  their  former  room  underwent  a thorough  disinfec- 
tion and  fumigation  for  ten  days,  after  which  they  again  occupied  it.  J 

“ All  their  clothes,  mattresses,  etc.,  which  remained  in  their  first  room  were  then  washed  and 
scalded,  deodorized  with  chlorine,  fumigated  with  sulphur,  disinfected  with  carbolic  acid  and 
abundantly  aired,  a continued  watch  being  kept  over  them,  night  and  day,  the  whole  time.  To 
their  clothing,  which  consisted  of  woolen  shirts  and  woolen  pants,  shoes  without  socks,  and  ft 
straw  hat,  and  which  they  did  not  change,  some  of  the  fever  germs  or  poison  must  have  adhered, 
and  when,  fourteen  days  later,  two  more  of  their  countrymen  arrived  here  from  Galveston,  and  lived*! 
with  them  in  the  same  room,  one  of  them  was  taken  sick  with  the  fever  within  three  days,  car- 


* “ Annual  Report  of  the  Board  of  Health  to  the  General  Assembly  of  Louisiana,  December  31st,  1871,” 
pp.  64-71. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  403 


ried  to  the  hospital  on  November  17th,  and  died  on  the  following  day.  The  other  took  sick 
within  seven  days,  November  20th,  and  died  November  23d. 

“ This  shows  that  although  disinfection  and  fumigation  will  destroy  the  poison,  still  minute 
contagious  particles  will  escape  its  influence,  and  that  during  a season  favorable  to  its  develop- 
ment, the  disinfection  must  be  continued  and  persevered  in  every  three  or  four  days  throughout 
the  season. 

“ No  other  person  in  that  yard  or  in  that  neighborhood  took  the  fever  afterward. 

“There  were  also  three  other  deaths  from  yellow  fever  in  the  Second  District — on  Franklin 
street,  between  Canal  and  Bienville  streets,  a distance  of  two  squares.  An  Italian,  by  the  name 
of  Dominique  Gaisalla,  who  had  resided  at  No.  38  Franklin  street  for  about  twelve  months,  and 
who  was  a lemon  peddler  by  occupation,  and  a friend  and  associate  of  the  above  mentioned  per- 
sons from  Malta,  at  No.  239J  Decatur  street,  and  in  daily  communication  with  them,  was  taken 
sick  October  26th,  and  died  October  30th.  He  was  not  attended  by  any  physician.  The  Coroner 
held  a ‘view’  on  his  body  and  had  him  buried  under  a certificate  of  ‘ congestion  of  the  brain.’ 

“Mrs.  Reese,  residing  at  No.  12  Franklin  street,  a native  of  Baltimore,  and  unacclimated,  was 
acquainted  with  the  before-mentioned  person  and  had  visited  him  during  his  sickness.  She  was 
taken  on  November  1st  and  died  November  6th  with  black  vomit.  The  husband  of  this  lady 
took  the  fever  about  December  18th,  and  remained  sick  until  December  28th,  when  he  died  of 
undoubted  yellow  fever,  according  to  the  burial  certificate  of  his  attending  physician,  at  No.  237' 
Dryades  street,  in  the  upper  part  of  the  city,  to  which  place  he  had  been  removed.  Frank 
Busoti,  an  Italian,  and  a waiter  in  a bar-room  and  restaurant  at  the  corner  of  Custom-house  and 
Franklin  streets,  visited  both  of  the  before-mentioned  persons  while  they  were  sick,  carrying 
them  refreshments  and  drinks.  He  took  yellow  fever  November  7th  and  died  the  14th.”* 

The  following  observations  should  be  coupled  with  the  preceding  statements  of  Dr.  Albers. 

1.  Dr.  Albers  states  that  no  cases  were  attacked  in  the  Fourth  District,  between  the  28th  of  Sep- 
tember and  the  4th  of  October,  when  he  withdrew  to  the  Second  District.  The  official  record  of 
the  Board  of  Health  shows  that  two  cases  occurred  in  this  district  on  the  28th  of  September,  at 
129  Washington  street  and  190  Third  street;  one  case  occurred  at  780  Magazine  street,  on  the 
■2d  of  October,  and  another  case  at  the  corner  of  Tchoupitoulas  and  7th  streets,  on  the  3d  of  Octo- 
ber. The  statement  of  Dr.  Albers  would  lead  one  to  suppose  that  the  disease  had  been  completely 
arrested  or  stamped  out  by  the  sanitary  measures,  and  especially  by  the  free  use  of  carbolic  acid. 
So  far  from  being  the  case,  53  cases  occurred  during  the  month  of  October,  against  37  in  the 
month  of  September,  and  after  the  vigorous  use  of  carbolic  acid  in  the  infected  district.  Of  the 
53  cases  officially  reported  for  October,  40  cases  occurred  in  the  thoroughly  “disinfected  ” Fourth 
District  in  which  the  disease  had  been  stamped  out. 

2.  It  appears  also,  from  the  statement  of  Dr.  Albers,  that  “ the  principal  hotbeds  of  the  fever, 
as,  for  instance,  on  Fourth,  Fifth  and  Magazine  streets,  were  entirely  deserted  by  their  occu- 
pants.” 

The  carbolic  acid  certainly  acted  as  a valuable  sign  and  warning  to  all  in  the  city  as  to  the 
location  of  the  yellow  fever,  and  thus  fulfilled  the  office  of  a local  and  very  efficient  quarantine. 

3.  The  disease  evidently  occurred  a second  time  in  houses  disinfected  and  surrounded  with 
disinfectants,  as  at  118  Washington  street,  where  cases  were  officially  recorded  as  occurring 
August  15th,  October  14th,  and  October  27th. 

A fatal  case  occurred  at  433  Tchoupitoulas  street  on  the  5th  of  September,  and  another  on  the 
12th  of  October.  Two  cases  occurred  at  140  Fourth  street  on  the  10th  and  11th  of  September; 
another  case  on  the  15th  ; another  on  the  20th  of  September  in  the  same  house.  A case  occurred 
at  119  Washington  street,  September  21st;  another  in  the  same  house  October  27th;  one  case  at 
780  Magazine  street,  September  27th,  and  another  October  2d.  One  case  at  129  Washington 
.street,  September  16th,  and  another,  September  28th,  and  a third  on  the  12th  of  October. 

The  following  singular  statement  occurs  in  the  report  of  the  President,  Dr.  C.  B.  White: — 

“By  the  culpable  neglect  of  the  attending  physician,  information  of  the  occurrence  of  the 
case  of  Mr.  Rawlins  did  not  reach  the  Board  of  Health  until  twenty  hours  after  his  decease. 
Measures  of  disinfection  could  not  be  put  in  operation  for  some  hours  later.”-)- 


* “ Annual  Report  of  the  Board  of  Health  to  the  General  Assembly  of  Louisiana,”  December  31st 
1871,  pages  65-08.  t “ Annual  Report  of  the  Board  of  Health,”  1871,  p.  17. 


404 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  experience  of  the  family  of  Mr.  D.,  the  brother-in-law  of  Mr.  Rawlins,  occupying  the 
other  half  of  the  double  tenement,  has  interest  in  connection  with  the  subject  of  disinfection. 
Believing,  from  the  beginning  of  the  case  of  Mr.  R.,  that  his  attack  was  yellow  fever,  the  resi- 
dence of  Mr.  D.  was  thoroughly  treated  by  disinfectants,  and  every  person  who  waited  upon  Mr. 
Rawlins,  or  even  visited  the  rooms,  on  coming  from  them  made  a complete  change  of  all  their 
clothing,  which  was  without  delay  carried  from  the  room  and  washed. 

No  case  of  yellow  fever  occurred  in  this  family  till  the  one,  No.  53,  on  October  14th,  and  No. 
90,  October  27th,  both  of  which  were  so  light  th  it  the  attending  physician  is  doubtful  of  the  diag- 
nosis given.  On  the  14th  and  15th  of  September  cases  occurred  in  houses  each  side  of  the  resi- 
dence of  Mr.  D.,  and  by  the  14th  of  October  there  had  been  twenty-seven  unmistakable  eases 
within  a circle  of  a radius  of  150  feet,  taking  the  house  of  Mr.  Rawlins  as  a centre. 

Owing  to  the  almost  complete  cessation  of  yellow  fever,  about  October  1st,  in  this  district,  gen- 
eral disinfection  had  ceased,  and  none  was  used  until  recurring  sultry  weather  and  the  appearance 
of  new  eases  of  fever  indicated  the  propriety  of  its  use.  The  experience  of  this  family  and  the 
use  of  disinfectants  may  be  only  a coincidence,  but  is  worthy  of  consideration  and  record. 

The  history  of  the  Fourth  District  epidemic  may  be  closed  with  the  statement  that  the  total 
number  of  cases  in  that  district,  measuring  one  and  three-fourths  miles  long  and  one  mile  wide, 
was  sixty-six,  of  which  twenty-four  terminated  in  death.  The  striking  localization  of  the  fever 
is  made  evident  by  the  fact  that  within  an  area  of  which  the  corner  of  Constance  and  Washing- 
ton (the  house  of  Rawlins)  is  the  centre,  and  extending  in  every  direction  from  that  point,  six 
hundred  and  sixty  feet,  occurred  45  of  the  total  cases  and  15  of  the  deaths.”* 

4.  Whatever  effects  the  sanitary  measures,  and  more  especially  disinfection  with  carbolic  acid, 

may  have  had  upon  the  spread  of  yellow  fever  in  the  Fourth  District,  the  changes  of  the  weather 
appear  to  have  exerted  even  more  important  effects.  Thus,  the  President  of  the  Board  of  Health, 
in  the  absence  of  any  official  record  of  the  temperature  and  changes  of  the  weather,  states  that 
“ During  the  prevalence  of  yellow  fever  this  year,  in  marked  contrast  to  last  year,  the  weather 
remained  warm,  exceedingly  sultry,  rainy,  with  a remarkable  stagnant  condition  of  the  atmo- 
sphere, greatly  resembling  the  early  period  of  the  epidemic  of  1853.”  . . . 

“On  October  3d  occurred  a violent  storm,  which  to  the  southward  and  eastward  assumed  the 
proportions  of  a hurricane.  The  rain  fell  in  enormous  amount,  flooding  yards  and  streets,  and 
the  violence  of  the  wind  thoroughly  ventilated  the  most  out-of-the-way  corners.  1 0 ^ inches  of 
rain  fell  in  twenty-four  hours.  By  examination  of  the  table  it  will  be  seen  that  the  Fourth 
District  epidemic  had  greatly  declined  before  the  coming  of  the  storm.  The  storm  seems,  how- 
ever, to  have  exerted  a decided  and  favorable  influence  on  the  public  health,  as  but  three  domestic 
cases  of  fever  died  in  the  next  fifteen  days,  the  three  other  deaths  being  of  cases  foreign  to  New 
Orleans.”! 

5.  That  portion  of  the  Fourth  District  in  which  the  yellow  fever  was  introduced  by  Mr.  Raw- 
lins is  not  a business  centre,  is  removed  from  the  shipping,  and  a vast  proportion  of  the  inhabitants 
were  permanent  residents  and  acclimated. 

6.  Yellow  fever  did  not  appear  in  the  Second  District  until  late  in  the  season,  the  first  cases 
observed  by  Dr.  Albers  being  on  the  2Gth  of  October.  The  arrest  of  the  disease  in  this  district 
was  fairly  attributable  to  the  supervention  of  cold  weather  rather  than  to  the  use  of  disinfectants. 
Dr.  Alfred  W.  Perry  states  that  “ only  five  cases  of  yellow  fever  were  reported  in  the  Third  District, 
against  59  deaths  in  1870;  two  of  the  five  cases  had  been  exposed  to  the  disease  in  Natchez,  and 
came  here  and  died  in  a few  days  afterward.  In  the  other  three  cases  no  particular  source  of  con- 
tagion could  be  traced,  although  there  may  have  been  such.  In  these  cases  the  houses  were  fumi- 
gated with  sulphurous  acid ; carbolic  acid  was  sprinkled  plentifully  in  the  vicinity  and  on  the 
premises,  so  that  its  vapor  would  diffuse  into  the  air.”  While  Dr.  Perry  says  that  “ the  good  effects  of 
this  action  are  shown  by  the  fact  that  no  second  ense  of  the  fever  occurred  in  the  same  house  or 
neighborhood,  while  during  the  preceding  year  many  succeeding  cases  occurred  in  the  same  house, 
and  that  the  fever  was  confined  to  one  or  two  blocks;  ” on  the  other  hand,  ho  neglects  to  stato  the 
fact  that  the  first  cases  occurred  in  1871,  in  the  Third  District,  on  the  24th  of  October,  when  the 
temperature,  of  course,  precluded  any  extensive  spread  of  the  disease. 


* “ Annual  Report  of  the  Board  of  Health,”  1871,  p.  20-21.  t Op.  cit.,  p.  25. 

7 “Annual  Report  of  the  Board  of  Health,’’  1871,  p.  75-7G. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  405 


James  J.  Jackson,  M.D.,  Sanitary  Inspector  of  the  Third  District,  states  that  in  1871  “the 
first  cases  of  yellow  fever  in  this  district  were  confined  to  the  shipping,  and  especially  to  vessels 
lying  beneath  the  level  of  the  wharves.  All  cases  occurring  on  shipboard  were  sent  to  the  hospital 
for  treatment  and  the  vessels  thoroughly  fumigated.  Late  in  the  season  the  disease  spread  to  the 
block  bounded  by  Elysian  Fields,  Frenchman,  Victory  and  Levee  streets,  where  it  was  confined 
until  its  final  abatement.  The  inhabitants  of  this  locality  were  principally  Italians,  who  lived 
huddled  together  in  small  apartments,  and  were  the  sole  victims  of  tho  fever.”* 

In  the  First  District,  1871,  the  first  case  of  yellow  fever  occurred  at  433  Tchoupitoulas  street, 
September  9th,  and  the  last  at  347  Dryades  street,  December  29th. 

No  well-marked  case  of  yellow  fever  occurred  in  the  Fifth  and  Sixth  Districts. 

In  considering  the  history  of  yellow  fever  in  1871  in  New  Orleans,  it  is  important  to  note  the 
fact  that  the  submergence  of  that  portion  of  the  First  and  Second  Districts  lying  between  the  old 
and  new  canals,  and  between  Basin  street  and  the  Metaire  Ridge,  resulting  from  the  break  in  the 
banks  of  the  new  canal  on  the  3d  of  June,  1871,  caused  by  the  elevation  of  the  waters  of  Lake 
Pontchartrain  after  a succession  of  strong  southeast  winds,  which  interfered  with  the  outflow  of  the 
■waters,  augmented  by  the  break  in  the  river  levee  at  Bonnet  Carre,  was  attended  neither  by  the 
appearance  of  yellow  fever  nor  by  an  increase  in  the  number  and  severity  of  the  ordinary  mala- 
rial fevers  in  the  overflowed  districts. 

The  privies  were  overflowed  in  this  district  and  much  of  their  contents  escaped,  and  when  the 
waters  became  stagnant,  and  as  the  filthy  streets  and  premises  were  gradually  exposed  to  the 
burning  rays  of  the  sun  in  June  and  July,  as  the  waters  receded  and  were  dissipated  by  evapor- 
ation a foul  stench  arose.  For  a series  of  years  the  St.  Charles,  St.  James  and  City  Hotels  and 
the  Charity  Hospital  have  been  daily  discharging  the  contents  of  their  privies  into  Gravier  and 
Common  streets,  and  the  filthy  streams  flowing  into  the  gutters  have  finally  found  their  way  into 
the  canals  and  drains  in  the  rear  of  the  city.  If  there  be  anything  in  filth,  and  especially  in 
human  filth  and  excrements,  combined  with  heat  and  moisture,  to  engender  yellow  fever  de  novo, 
such  conditions  are  annually  present  in  New  Orleans,  and  yet  the  district  of  the  city  in  which  the 
largest  amount  of  human  excrements  is  poured  has  been  remarkably  exempt  from  yellow  fever. 
This  disease  has  almost  invariably  originated  in  and  about  the  shipping  along  the  river  front  and 
in  the  new  and  old  basins. 

The  President  of  the  Board  of  Health,  in  his  official  report,  thus  congratulates  himself  and 
his  assistants  on  the  use  of  disinfectants  during  the  summer  and  autumn  of  1871  : — 

“The  experience  of  the  year  is  in  favor  of  their  use.  Some  families  in  which  they  were  used 
freely  on  the  occurrence  of  the  first  case  escaped  additional  attacks.  Other  families  in  which,  by 
prejudice  or  neglect  of  the  physicians,  or  their  own  choice,  they  were  not  used,  the  disease  passed 
through  the  whole  family,  attacking  all  its  members  in  succession. 

“The  general  prevalence  of  the  disease  in  the  Southern  States,  and  numerous  cases  scattered 
about  in  New  Orleans,  show  that  the  failure  of  the  fever  to  become  general  was  not  owing  to  any 
unfavorable  meteorological  or  climatic  conditions. 

“ Last  year  New  Orleans  suffered  from  yellow  fever.  Its  ravages  were  confined  to  three  blocks 
in  the  Third  District,  a limited  portion  of  the  Fifth  District,  and  as  an  epidemic  it  was  confined 
to  a portion  of  the  Second  District  of  four  squares  by  twelve.  In  Mobile  it  began  later  than  in 

I New  Orleans,  but  attacked  every  portion  of  the  city.  In  New  Orleans  great  efforts  were  made  to 
arrest  the  disease  by  hygienic  remedies.  No  efforts  whatever  were  made  in  Mobile.  This  fact 
seems  of  value.  In  every  Southern  city,  town  or  village  where  yellow  fever  appeared  at  all  this 
year  it  assumed  the  epidemic  form,  save  in  New  Orleans,  and  New  Orleans  is  the  only  place 
where  an  early,  energetic,  well-planned  and  persistent  attempt  was  made  to  control  the  disease.’’^ 

YELLOW  FEVER  OF  1872. 

Total  deaths  in  New  Orleans  in  1872,  less  still-born,  6122 ; still-born,  466 ; total  deaths,  including 
still-born,  6588.  The  following  deaths  were  caused  by  the  various  forms  of  fever  : Fever,  1 ; 
bilious,  22 ; congestion,  165;  gastric,  1 ; hectic,  2 : intermittent,  27;  malarial,  51;  nervous,  1; 
puerperal,  10;  remittent,  26;  scarlet,  5;  typhoid,  67;  typhus,  4;  yellow,  39;  total  deaths  by 


* “Annual  Keport  of  the  Board  of  Health,”  1870,  p.  49. 
f “Annual  Report  of  the  Board  of  Health,”  1871,  pp.  25,  26. 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


406 

t 

fevers,  401;  consumption,  784;  infantile  convulsions,  227 ; diarrhoea,  195;  cholera  infantum,  52; 
cholera  morbus,  20;  dysentery,  123;  inflammation  of  bowels,  150;  total  by  bowel  affections,  440; 
smallpox,  29. 

Total  admissions  Charity  Hospital,  5541 ; total  deaths,  825 ; fever,  intermittent,  cases  909 ; 
malarial,  cases  431,  deaths,  28;  remittent,  cases  41,  deaths,  1;  bilious,  cases  28,  deaths,  3; 
typhoid,  cases  21,  deaths,  7 ; continued,  cases  10,  deaths,  1;  dengue,  cases  1;  typho-malarial, 
cases  5,  deaths,  2;  yellow,  cases  11,  deaths,  8;  ephemeral,  cases  1;  puerperal,  cases  4,  deaths,  3; 
congestive,  cases  24,  deaths,  18;  bilious  remittent,  cases  2,  deaths,  2;  diarrhoea,  cases  298,  deaths, 
95;  dysentery,  cases  289,  deaths,  59;  total  bowel  affections,  cases  594,  deaths,  156. 

The  epidemic  of  this  year,  if  it  could  be  called  such,  was  still  more  limited,  only  83  cases  and 
3§  deaths  having  been  officially  reported.  The  monthly  deaths  were  as  follows : August,  1 ; 

September,  5;  October,  24;  November,  7;  December,  2.  On  the  other  hand,  the  eo-called  con- 
gestive fever  destroyed  165. 

The  disease  was  widely  scattered  over  the  city,  commenced  late  in  the  season,  and  showed  no 
tendency  to  spread;  17  cases  were  reported  in  the  First  District,  4 cases  in  the  Second  District,  1 
case  in  the  Third  District,  59  cases  in  the  Fourth  District,  1 case  in  the  Fifth  District,  1 case  in 
the  Sixth  District. 

The  mortality  of  these  “disinfected”  cases  was,  in  like  manner  great,  reaching  nearly  50  per 
cent.  > 

The  Fourth  District  originated  61  of  the  cases. 

The  yellow  fever  area  of  1872  surrounded  the  yellow  fever  area  of  1871,  and  scarcely  a case 
occurred  this  year  in  the  locality  where  it  prevailed  last  year.  The  central  points  of  most  potent 
yellow  fever  infection  existed  at  the  corner  of  Magazine  and  Jackson  streets. 

The  following  facts  are  consolidated  from  the  interesting  reports  of  Dr.  A.  W.  Perry,  Sanitary 
Inspector  of  the  Fourth  District,  where  the  yellow  fever  first  appeared  and  to  which  it  was  chiefly 
confined. 

It  will  be  observed  from  the  report  of  Dr.  Perry  and  from  the  preceding  reports  of  the  Presi- 
dent of  the  Board  of  Health,  that  the  yellow  fever  of  1872  commenced,  as  in  1871,  in  one  of  the 
most  healthy  and  cleanly  portions  of  the  Fourth  District,  which  is  regarded  as  the  best  part  of  the 
city.  In  1870  yellow  fever  was  confined  to  a portion  of  the  city  four  by  twelve  blocks  wide  and 
deep  in  the  Second  District  of  the  city,  and  to  a locality  ten  by  six  blocks  wide  and  deep  in  the 
First  District,  both  of  which  are  well  built  and  paved,  are  near  the  river,  and  are  usually  espe- 
cially free  from  malarious  diseases.  In  1871  and  1872  the  disease  occurred  in,  and  was  almost 
wholly  confined  to,  limited  portions  of  the  Fourth  District,  portions  of  the  district  less  liable  to 
swamp  fevers  than  its  other  parts,  and  far  more  healthy  in  that  respect  than  the  rear  portion  of  the 
city  bordering  the  swamps  for  miles.  The  localized  infection  of  yellow  fever  during  these  years 
established  a marked  difference  between  this  disease  and  the  endemic  paroxysmal  fevers  of  the 
Mississippi  Valley. 

The  first  case  occurred  August  28th,  in  the  person  of  Frank  Henning,  a native  of  Sweden,  aged 
thirty-six  years,  two  years  in  the  city;  a druggist  by  occupation,  and  employed  in  a drug  store 
corner  of  Washington  and  Rousseau  streets,  where  he  was  taken  sick.  He  was  sick  in  the  drug 
store  two  days,  then  went  to  a house  on  Livandais  street,  almost  a hundred  yards  distant,  where  he 
remained  two  days,  and  was  then  sent  to  the  Hotel  Dieu,  where  ho  died  September  1st.  Although 
the  most  careful  inquiry  was  made,  no  history  could  be  traced  of  the  disease  having  been  imported. 
“This  case  may  be  considered  as  the  starting  point  of  the  yellow  fever  of  this  year,  for  from  this 
case  six  persons,  who  had  direct  and  recent  communication,  were  attacked  with  yellow  fever.  The 
first  of  these  secondary  cases  was  a young  man  who  waited  on  Henning.  Another  was  a young 
lady  whom  this  last  young  man  visited  immediately  after  recovering  from  the  yellow  fever.  Two 
others  were  fellow  clerks  in  the  same  store  with  Henning,  the  first  case.  In  one  other  case  the 
man  attacked  frequently  visitod  Henning  in  the  drug  store,  and  soon  after  was  taken  sick  with  the 
fever,  and  his  wife  also.  The  disease  continued  to  increase  slowly  in  a few  limited  areas  in  this 
district,  until  October  13th,  when  it  reached  its  highest  point.”  The  following  record  shows  the 
gradual  rise  and  decline  during  October:  1st,  l case;  2d,  3 cases;  3d,  2 cases;  7th,  1 case;  8th,  2 
eases;  9th,  1 case;  10th,  2 cases;  11th,  1 caso;  12th,  3 cases;  13th,  7 cases;  14th,  1 case;  15th, 
1 case;  18th,  4 cases;  19th,  2 cases;  20th,  1 case;  21st,  2 cases. 

“ A case  occurred  on  Rousseau  street,  between  Jackson  and  Philip,  which  gave  origin  to 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  407 

seven  others,  and  a group  of  thirteen  cases  occurred  within  150  yards  of  the  corner  of  Jackson 
and  Magazine  streets.  There  occurred  10  cases  in  September,  37  in  October,  10  in  November, 
making  a total  of  57  in  the  Fourth  District.  The  fever  has  shown  the  same  tendency  as  last 
year  to  confine  itself  to  small  localities,  and  it  has  shown  itself  to  be  exceedingly  communicable. 
The  frequent  communication  of  yellow  fever  this  year  is  probably  not  a new  feature  in  the  dis- 
ease, but  is  shown  strongly  this  season,  because  all  cases  were  promptly  reported,  and  the  details 
of  the  cases  were  kept.  Out  of  57  cases  originating  in  this  district,  in  27  there  was  recent  and 
direct  communication. 

“All  of  the  houses  where  the  disease  occurred  were  disinfected  with  carbolic  acid  in  the  fol- 
lowing manner : — 

“ When  the  case  was  reported,  a few  gallons  of  crude  carbolic  acid  were  sprinkled,  with  a 
watering  pot,  around  the  house,  in  the  yard  and  adjacent  streets.  The  object  of  this  was  to  cause 
an  impregnation  of  the  air  of  the  locality  with  carbolic  acid  vapor.  On  the  termination  of  the 
case,  either  in  recovery  or  death,  rooms  in  which  the  patient  had  been  were  disinfected  by  throw- 
ing a few  sprays  of  pure  carbolic  acid,  diluted  with  fifty  parts  of  water,  into  every  part  of  the 
rooms,  upon  the  walls,  ceiling,  furniture.  In  the  form  of  a fine  spray  a minute  portion  of  car- 
bolic acid  was  thus  brought  in  contact  with  everything  in  the  room,  and  every  organic  germ 
must  have  been  destroyed.  All  bedding  and  clothing  which  had  been  used  was  either  boiled  or 
soaked  in  diluted  carbolic  acid.  I found,  by  direct  experiment,  that  pure  carbolic  acid  dissolves 
readily  in  fifty  parts  of  water,  forming  a clear  solution  which  does  not  stain  or  injure  the  most 
delicate  colors  of  calico,  silk  or  broadcloth,  and  yet  is  strong  enough  to  destroy  the  vitality  of  all 
the  lower  forms  of  life.  The  use  of  any  well-directed  system  of  disinfection  in  a disease  neces- 
sarily involves  a theory  of  the  nature,  production  and  communication  of  the  disease.  Our  sys- 
tem of  disinfection  is  based  on  these  propositions  : — 

“ 1.  That  yellow  fever  is  produced  by  an  organic  living  germ. 

“2.  That  it  is  portable  in  ships,  cars,  clothing,  etc. 

“ 3.  That  it  is  solid,  and  not  readily  diffused  through  the  air,  but  sticks  to  solid  bodies. 

“ One  attack  of  yellow  fever  is  usually  a protection  against  another.  The  apparent  exceptions 
to  this  protecting  influence  of  a first  attack  are  more  frequent  than  in  smallpox,  but  most  of  these 
exceptions  must  vanish  when  it  is  remembered  that  in  mild  yellow  fever  there  is  no  pathogno- 
monic sign,  like  the  corruption  in  the  exanthemata,  and  a certain  distinctive  diagnosis  cannot 
be  made  from  malarial  fevers.  The  local  exceptions  are  not  more  numerous  than  in  smallpox. 
That  yellow  fever  is  portable  is  generally  admitted,  and  too  many  instances  are  on  record  in  all 
medical  works,  where  vessels  have  arrived  in  seaports  of  the  United  States  and  Europe  with 
cases  of  yellow  fever  on  board,  and  large  numbers  of  persons  who  visited  these  vessels  have  been 
attacked  with  yellow  fever,  to  require  any  extended  proofs  here.  A vessel  loaded  with  sugar 
arrived  from  Cuba  at  St.  Nazaire,  France,  in  July,  1861 ; four  cases  of  yellow  fever  had  occurred 
on  the  voyage.  The  last  case  was  well  thirteen  days  before  the  vessel  arrived  in  St.  Nazaire. 
Within  a few  days  after  her  arrival  well  marked  yellow  fever  attacked  the  men  who  visited  the 
vessel,  those  who  were  engaged  in  unloading  her,  some  of  the  crews  of  vessels  lying  near,  and 
I some  persons  living  in  the  town  who  had  no  direct  communication  with  the  vessel  were  attacked. 
In  all  there  were  44  cases  and  26  deaths. 

“ If  we  admit  that  yellow  fever  depends  on  a living  germ  it  is  theoretically  possible  to  control 
the  spread  of  yellow  fever  by  destroying  the  life  of  these  germs.  The  difficulty  is  to  find  them 
exactly.  We  find  by  experience  that  the  winter  here  either  destroys  these  germs  or  suspends 
their  vitality.  The  probability  is  that  most  of  them  are  destroyed,  and  only  a few  are  left,  and 
that  when  the  yellow  fever  occurs  here  without  importation  it  is  caused  by  these  germs  which 
have  remained  over  from  last  year.  This  is  rendered  probable  from  the  circumstance  that 
I yellow  fever  only  makes  its  appearance  here  after  hot  weather  has  lasted  two  or  three  months.  It 
is  likely  that  the  yellow  fever  germs,  whose  vitality  was  only  suspended,  revive  when  the  hot 
weather  commences,  and  that  they  require  this  interval  before  they  have  multiplied  sufficiently  to 
i make  themselves  felt  by  causing  disease.  The  less  number  of  germs  that  are  left  alive  the  longer 
time  will  be  required  to  produce  the  requisite  quantity.  Every  germ  that  can  be  destroyed  in  the 
first  or  first  few  generations  is  equivalent  to  destroying  millions  in  the  later  generations.  If  this 
were  not  so,  and  all  the  germs  which  are  left  at  the  end  of  the  fall,  scattered  around  the  city, 
were  to  revive  the  next  year  in  the  first  warm  or  damp  weather,  it  would  attain  its  full  devolop- 


408 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ment  suddenly,  instead  of  gradually  spreading  from  one  or  more  points,  and  requiring  months 
for  its  full  development.  In  the  fever  zone,  as  I may  call  it,  if  any  hygienic  measures  will 
delay  the  development  of  the  disease  until  the  cold  weather,  it  is  practically  almost  as  good  as 
totally  destroying  the  disease.  A disease  germ  cannot  originate  anew ; it  must  be  the  descend- 
ant of  some  parent  germ,  and  it  is  simply  ridiculous  for  us  to  run  to  spontaneous  generation  when- 
ever we  meet  a living  individual  whose  parents  are  not  apparent.  There  is  no  experimental  evi- 
dence of  the  new  creation  of  any  living  thing,  from  the  lowest  to  the  highest  organized  animal; 
and  there  is  an  immense  weight  of  evidence  against  it.  In  any  house  where  one  or  more  persons 
have  been  taken  with  the  yellow  fever  there  are  certainly  some  few  germs  present  on  the  premises. 
By  sprinkling  carbolic  acid  on  the  ground  in  the  vicinity,  we  destroy  some  diseased  germs ; the 
vapor  of  the  acid,  diffusing  in  the  air,  kills  others.  In  disinfecting  a room  we  use  an  apparatus  to 
throw  a solution  of  carbolic  acid  in  the  form  of  a spray  which  is  so  fine  that  it  diffuses  itself  in 
every  direction,  in  every  crevice  and  fold,  and  yet  each  particle  is  a liquid,  and  as  such  has  a 
stronger  and  more  certain  effect  in  destroying  vitality ; for  it  is  well  known  that  the  liquid  condi- 
tion is  absolutely  necessary  for  the  chemical  actions  of  substances  on  each  other.  The  apparatus 
used  to  produce  this  spray  is  composed  of  a copper  vessel,  holding  two  gallons  of  water,  which  is 
placed  on  a small  sheet-iron  furnace,  and  in  which  steam  is  generated  to  the  pressure  of  four  to 
five  pounds  to  the  inch  ; connected  to  this  is  a quarter-inch  rubber  tube,  eight  feet  long,  through 
which  the  steam  is  conveyed  to  a brass  nozzle,  with  an  opening  one-sixteenth  inch  in  diameter. 
The  carbolic  acid  solution  is  supplied  to  the  steam  nozzle,  so  that  it  flows  slowly  over  the  jet  of 
steam,  which  breaks  the  liquid  up  into  the  finest  spray.  The  steam  kettle  is  placed  in  the  mid- 
dle of  an  apartment,  and  the  steam  nozzle  and  reservoir  of  carbolic  acid  solution  are  carried  around 
the  room,  and  the  resultant  carbolic  acid  spray  directed  upon  everything  which  is  required  to  be 
disinfected. 

“ In  the  history  of  yellow  fever  this  year  it  will  be  observed  that  it  required  more  than  six 
weeks  from  the  first  case,  August  28th,  for  it  to  reach  its  climax,  October  13th,  seven  cases  being 
attacked  that  day,  though  it  declined  rapidly  to  only  one  case  in  the  second  week  in  November. 
The  decrease  of  the  fever  above  shown  can  only  have  resulted  from  two  causes,  which  have  not 
been  in  operation  in  some  previous  years. 

“ The  disinfection  with  carbolic  acid  certainly  destroyed  a large  number  of  disease  germs, 
and  the  growing  and  very  prevalent  belief  in  the  communicability  of  the  fever  had  caused  many 
families  to  send  off  the  well  members  as  soon  as  any  one  was  taken  sick  with  the  fever  and  has 
also  cut  off  a large  proportion  of  the  intercourse  with  the  infected.  From  August  28th  to  Novem- 
ber 15th  there  was  no  change  in  the  temperature  or  barometric  pressure  which  could  account  for 
the  diminution  of  the  disease.  The  maximum  daily  temperature  varied  only  6.3°  F.,  and  the 
barometric  pressure  one  inch.  On  November  loth  the  weather  suddenly  changed,  to  be  very 
cold,  the  temperature  falling  to  33°  F. 

“ The  large  proportion  of  cases  in  which  the  disease  has  been  shown  to  have  been  communicated 
shows  the  disease  had  a strong  tendency  to  spread.  The  yellow  fever  reached  its  highest  point 
October  13th,  and  the  cold  weather  first  came  one  month  afterward,  and  then  the  fever  had  almost 
disappeared.”* 

It  will  be  seen  that  the  preceding  theory  of  the  nature  of  yellow  fever  and  of  the  principles  of 
disinfection  to  be  practiced  for  its  arrest,  as  represented  by  Dr.  Perry,  did  not  differ  from  that  of 
the  President  of  the  Board  of  Health  in  1867,  Dr.  Smith,  nor  from  that  of  Dr.  Albers  previously 
recorded;  nor  from  that  of  Dr.  C.  B.  White.  The  President  of  the  Board  of  Health,  writing  con- 
cerning the  yellow  fever  of  1871  says  : “ It  was  kept  clearly  in  view  that  though  the  sick  persons 
were  confined  to  a limited  space,  yet  the  poison  was  of  necessity  more  widespread.  It  is  evident 
that  the  presence  of  the  poisonous  agent  must  and  does  precede  for  some  hours,  if  not  days,  the 
attacks  of  illness.  The  peculiar  localization  of  yellow  fever,  as  observed  in  previous  years,  an  1 
its  slow  and  regular  march  forward  in  these  localities,  suggests  that,  if  it  bo  the  multiplication 
and  spread  of  either  vegetable  or  animal  life,  agents  powerfully  inimical  thereto,  although  not 
able  to  reach  all  hidden  and  closed  places,  and  thus  utterly  destroy  all  germs,  might,  at  least, 
destroy  those  likely  to  be  carried  or  wafted  in  to  infect  neighboring  localities.  If  the  poisonous, 
or  poison-causing  agent  spread  along  the  ground,  it  seemo  1 not  unreasonable  to  hope  that  a pow- 


* “Annual  Report  of  the  Board  of  Health,”  December  31st,  1872,  pages  93-98. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  409 


erful  agent,  like  carbolic  acid,  freely  applied  to  the  streets,  would  prevent  its  crossing  them,  and 
by  its  vapor  rising  into  the  air,  as  it  were,  wall  in  the  infected  places. 

‘‘The  effect  of  the  thinnest  possible  film  of  corrosive  sublimate  in  preventing  insects  from  cross- 
ing into  safes  and  cupboards  is  a fact  of  domestic  economy  well  known.  There  may  be  remedies 
of  analogous  action  toward  the  cause  of  yellow  fever.  . . . 

“ These  facts  seem  to  suggest  that  the  yellow  fever  plant,  or  contagium  particle,  may,  by  its 
growth,  or  during  its  development  and  general  prevalence,  exhaust  its  soil  (the  locality  of  its  mor- 
bific influence)  of  those  elements  necessary  to  its  growth,  and  which  may  require  some  time  to 
again  accumulate.  It  is  not  difficult  to  conceive  of  a vegetable  growth  so  developed  by  unusually 
favorable,  known  or  unknown,  climatic  or  meteorological  conditions,  as  to  almost  exhaust  its  soil 
of  the  ingredients  peculiarly  necessary  to  its  existence,  and  to  so  considerable  a degree  that  for 
successive  years,  in  unfavorable  conditions,  the  same  growth  should  be  but  feeble  and  of  scanty 
distribution.  Experience  seems  to  teach  that  if  the  disinfection  practiced  this  year  be  of  value, 
a repetition  of  it  at  brief  intervals  is  probably  necessary.  Begging  the  truth  of  the  “ Germ 
Theory,”  it  is  easy  to  make  a plausible  explanation  of  this  necessity.  The  cause  of  yellow  fever 
is  invisible  or  microscopic,  but  is  present  in  abundance.  Disinfection  reaches  and  destroys  the 
larger  portion  of  these  animal  or  vegetable  organisms,  and  checks  the  progress  of  the  disease,  or 
even  completely  destroys  it.  The  conditions  of  soil  and  meteorological  conditions  are  favorable,  or  the 
disease  would  not  have  appeared,  and  still  remain  favorable.  The  few  germs  not  reached  multiply 
i rapidly,  and  in  a few  days  the  morbific  cause  is  ready  to  attack  any  who  come  within  its  influence.” 

The  preceding  observations  are  presented  not  for  the  purpose  of  discussion,  but  simply  to  illus- 
i trate  the  theories  upon  which  the  Board  of  Health  conducted  its  “system  of  disinfection”  with 
I carbolic  acid ; but  we  may  observe  that  the  cases  occurring  in  the  Fourth  District  might  be 
i variously  cited,  according  to  the  views  of  the  writer,  as  causes  of  direct  contagion,  of  the  portability 
i of  infection  or  of  exposure  to  a poison  common  to  the  locality  in  and  around  the  drug  store  in  which 
the  first  case,  Henning,  worked. 

CHOLERA  AND  YELLOW  FEVER  OF  1873. 

The  year  1873  was  characterized  by  the  prevalence  in  New  Orleans  of  Asiatic  cholera,  cerebro- 
4 spinal  meningitis,  smallpox  and  yellow  fever.  The  total  deaths,  including  still-born,  numbered 
I 7995;  excluding  still-born,  7505;  deaths  from  the  various  forms  of  cholera,  359;  deaths  from 

1 smallpox,  505 ; deaths  from  yellow  fever,  226 ; deaths  from  meningitis  and  cerebro-spinal  menin- 
gitis, 174;  total  deaths  from  these  diseases,  1264.  If  the  deaths  from  these  diseases  and  those 

I still-born  be  subtracted  from  the  total  mortality,  the  remainder,  6241,  is  about  a fair  average  of 
the  mortality  for  the  last  ten  years. 

The  various  forms  of  fever  occasioned  the  following  number  of  deaths  : Fever,  5 ; bilious,  28  ; 
congestive,  246;  dengue,  6;  gastric,  3;  intermittent,  16;  malarial,  109;  nervous,  5;  puerperal, 
17;  remittent,  40;  scarlet,  5;  typhoid,  57;  typhus,  5;  yellow,  226.  Total  by  the  various  forms 
of  fever,  768;  various  forms  of  fever  exclusive  of  yellow  fever,  542. 

Affections  of  the  bowels  caused,  respectively,  the  following  deaths:  Cholera  sporadica,  142; 
i cholera  infantum,  118;  cholera  morbus,  99;  diarrhoea,  acute  and  chronic,  209,  dysentery,  acute 
I and  chronic,  153 ; inflammation  of  bowels,  152.  Total  deaths  from  bowel  affections,  873.  In  1872 
: the  total  deaths  caused  by  bowel  affections  numbered  only  440,  and,  in  view  of  the  great  increase 
in  1873,  it  would  be  more  accurate  to  place  the  deaths  by  Asiatic  cholera  (the  so-called  cholera 
' sporadica  of  the  Board  of  Health)  at  about  433  deaths,  against  142  entered  upon  the  “official” 
o reports.  • 

505  deaths  were  caused  in  1873  by  smallpox — a preventable  disease  and  imported;  about  433 
S deaths  were  caused  by  Asiatic  cholera,  imported  from  Europe ; 226  deaths  by  yellow  fever,  imported 
a from  the  West  Indies,  and  542  deaths  by  the  various  other  forms  of  fever,  which  were  due  to 
causes  which  might,  to  a great  extent,  be  controlled  by  drainage,  improved  hygiene  of  the  streets, 
i drains,  canals,  gutters,  privies  and  habitations  of  New  Orleans. 

I The  yearly  death  rate  for  1873  was  high,  being  37.05  per  thousand  of  living  inhabitants,  and 
i if  the  officially  reported  deaths  by  smallpox  505,  cholera  241,  and  yellow  fever  226,  be  excluded,  the 
death  rate  was  31.72  per  thousand  of  living  inhabitants. 


* “Annual  Report  of  the  Board  of  Health,"  1871,  pages  18-20. 


410 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


1236  white,  783  colored  children  under  two  years  of  age  died  during  1873,  and  in  relation  to 
population,  according  to  the  United  States  census  of  1870,  181.56  white  and  335.47  colored  children 
under  two  years  of  age  died  per  1000  of  population  in  these  ages  and  classes,  respectively.  Infan- 
tile convulsions  caused  256  deaths,  and  consumption  850. 

In  the  Charity  Hospital  the  admissions  numbered  5090,  deaths  993;  of  those  admitted,  3029 
were  foreigners  and  2035  natives  of  the  United  States,  and  of  these  latter  672  were  natives  of 
Louisiana. 

Of  the  various  forms  of  fever  treated  in  the  Charity  Hospital;  Intermittent,  cases  687,  deaths 
5;  malarial,  cases  510,  deaths  59;  typho-malarial,  cases  2,  death  1;  remittent,  38  cases,  2 deaths; 
typhoid,  17  cases,  5 deaths;  bilious,  9 cases,  2 deaths;  bilious  remittent,  9 cases,  2 deaths;  catar- 
rhal, 2 cases;  pernicious,  7 cases,  6 deaths;  puerperal,  2 cases,  1 death;  congestive,  13  cases,  11 
deaths;  continued,  6 cases;  dengue,  88;  Chagres,  1;  yellow,  118  cases,  75  deaths;  scarlet,  1 case, 

1 death;  urethral,  1 case,  1 death.  Of  bowel  affections:  Cholera,  34  cases,  27  deaths;  cholera 
morbus,  12  cases,  9 deaths ; diarrhoea,  277  cases,  53  deaths ; dysentery,  185  cases,  73  deaths ; Phthisis 
pulmonalis,  214  cases,  136  deaths. 

The  first  case  of  yellow  fever  which  occurred  in  1873  was  traced  to  the  bark  “Valparaiso,” 
which,  after  a so-called  thorough  disinfection  and  fumigation  at  the  quarantine  station,  arrived  in 
New  Orleans  June  26th.  The  first  case  occurred  on  the  4th  of  July  and  died  on  the  8th.  Of  the 
226  deaths  by  yellow  fever  only  68  were  Americans.  Of  the  388  cases  and  226  deaths,  the  monthly 
record  was  as  follows:  July,  8 cases,  5 deaths;  August,  40  cases,  29  deaths;  September,  184  cases. 

108  deaths;  October,  135  cases,  79  deaths;  November,  22  cases,  14  deaths. 

The  President  of  the  Board  of  Health  states  that  the  above  were  all  that  were  reported  to  the 
Board  of  Health,  “though  probably  10  per  cent,  of  all  the  recoveries  were  not  reported.  Many 
physicians  did  not  report  their  cases  until  the  strongest  evidences  of  dissolution  were  apparent.” 

If  this  statement  be  true,  as  it  undoubtedly  is  far  within  the  actual  bounds  of  the  cases  not 
reported,  and  if,  at  the  same  time,  it  be  affirmed  that  the  disease  was  limited  and  arrested  by  the 
“ carbolic  acid  disinfection,”  why,  it  may  be  asked,  did  yellow  fever  not  spread  from  those  centres 
where  it  was  not  reported,  and  in  which  no  disinfection  of  any  character  was  practiced  ? 

These  facts,  on  the  contrary,  show  in  the  clearest  manner  that  the  limited  nature  of  the  epi- 
demic was  due  to  the  peculiar  conditions  of  the  climate  and  population. 

It  is  worthy  of  note  that  in  1873  the  various  forms  of  fever,  exclusive  of  yellow  fever,  caused 
537  deaths,  of  which  number  congestive  fever  caused  246  deaths,  and  the  so-called  malarial  fever 

109  deaths.  The  total  deaths  from  fevers  in  1873  numbered  763. 

The  plan  of  disinfection  pursued  in  1873  did  not  differ  materially  from  that  of  1872  : the 
streets  of  the  infected  district  were  sprinkled  with  carbolic  acid,  and  this  agent  was  distributed 
over  an  area  considered  to  be  beyond  the  point  actively  infected  by  the  fever  contagion.  The 
premises  in  the  vicinity  of  the  case — -yard,  walks,  etc. — were  disinfected  with  colorless  carbolic 
acid,  dissolved  in  water  by  means  of  hand  sprinkling  pots.  When  the  case  terminated  by  death, 
removal  or  recovery,  the  premises  were  disinfected.  Floors  were  sprinkled  with  dilute  white 
carbolic  acid,  clothing  and  bedding  either  sprinkled  in  the  same  way  or  freely  with  boiling  water. 
Walls,  ceilings  and  furniture  were  disinfected  by  a steam  atomizer,  throwing  a spray  of  dilute 
white  carbolic  acid. 

YELLOW  FEVER  OF  1874. 

Total  deaths  in  New  Orleans,  1874,  exclusive  of  still-born,  6798,  including  still-born  (495),  7293. 
Cholera  sporadica,  6 ; cholera  morbus,  11  ; cholera  infantum,  80  ; diarrhoea,  chronic  and  acute,  182;  _ 
dysentery,  chronic  and  acute,  150;  inflammation  of  bowe'.s,  140;  total  diseases  of  bowels,  469; 
consumption,  810;  inflammation  of  lungs,  258;  pneumonia,  15;  smallpox,  587;  fever,  l: 
continued,  9;  congestive,  254;  intermittent,  37;  malarial,  122;  nervous,  1;  puerperal,  20  ;> 
remittent,  62 ; scarlet,  4;  typhoid,  95;  typho-malarial,  13  ; typhus,  2 ; yellow,  11;  total  deaths 
from  fevers,  631. 

Total  admissions,  Charity  Hospital,  5231  ; deaths,  860.  Of  the  admissions,  foreigners,  301  ■>, 
natives  of  United  States,  2201,  including  764  natives  of  Louisiana.  Diarrhma,  cases  3S1,  deaths  82;^ 
dysentery,  cases  74,  deaths  42  ; phthisis  pulmonalis,  cases  287,  deaths  145  ; pneumonia,  cases  121, 
deaths,  37.  Fevers,  malarial,  cases  712,  deaths  95  ; intermittent,  cases  929;  remittent,  cases  62; 
typho-malarial,  cases  9,  deaths  5;  pernicious,  cases  1,  deaths  1 ; typhoid,  cases  5,  deaths  4;  eon- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  411 


gestive,  cases  4,  deaths  3 ; yellow,  cases  9,  deaths  fi  ; bilious,  cases  2;  catarrhal,  cases  2 ; dengue, 
cases  2 ; continued,  cases  3. 

Yellow  fever  caused  only  11  deaths,  6 of  which  occurred  in  the  Charity  Hospital.  Smallpox, 
on  the  other  hand,  caused  587  deaths.  The  various  forms  of  fever  caused  631  deaths,  the  greater 
portion  of  which,  namely,  413,  were  caused  by  congestive,  intermittent  and  malarial  fevers. 

The  cases  and  deaths  from  smallpox  were  as  follows:  January,  cases  154,  deaths  82;  February, 
cases  196,  deaths  89;  March,  cases  203,  deaths  99;  April,  cases  248,  deaths  97  ; May,  cases  230, 
deaths  98;  June,  cases  141,  deaths  66;  July,  cases  65,  deaths  30;  August,  cases  12,  deaths  6; 
September,  cases  13,  deaths  6;  October,  cases  8,  deaths  3 ; November,  cases  23,  deaths  12  ; De- 
cember, cases  45,  deaths  17;  total  cases,  1338  ; total  deaths,  605.  Six  hundred  and  five  deaths  by 
smallpox  are  at  the  rate  of  2.88  deaths  per  1000  population,  and  8.90  per  cent,  of  the  total  death 
rate.  Of  1338  cases  of  smallpox  712  were  white  and  626  colored,  a rate  of  4.59  cases  to  1000  of  white 
population,  and  11.38  cases  to  1000  of  colored  population,  estimating  white  population  at  155,000  and 
! colored  at  55,000.  The  total  number  of  deaths  for  1874  was  6798.  The  total  death  rate  per  1000 
per  annum  was  32.37,  and  the  annual  death  rate,  had  not  smallpox,  an  eminently  preventable  dis- 
■ ease,  prevailed,  would  have  been  29.49.  In  the  face  of  such  facts,  the  President  of  the  Board  of 
Health  affirms  “ that  persistent  and  decided  effort  was  made  by  isolation,  disinfection  and  ventila- 
I tion  to  prevent  the  spread  of  smallpox.”  * The  number  of  deaths  from  smallpox  entered  upon  the 
mortuary  report  differed  from  those  just  given  as  officially  reported  to  the  Board  of  Health,  and 
presented  in  tabular  form,f  thus:  January,  deaths  87  ; February,  82  ; March,  88  ; April,  94;  May, 
79;  June,  73;  July,  41 ; August,  10;  September,  6 ; October,  2 ; November,  10;  December,  15; 
i total,  587. 

One  hundred  and  ten  deaths  were  recorded  as  caused  by  typhoid,  typho-malarial  and  typhus 
i fever;  ninety-five  of  these  were  recorded  as  due  to  typhoid  fever.  The  heaviest  mortality  from 
» these  diseases  occurred  during  the  months  of  June,  July,  August,  September  and  October,  and  the 
deaths  were  as  follows:  January,  3;  February,  1;  March,  2;  April,  2;  May,  4;  June,  13;  July, 

124  ; August,  19  ; September,  11 ; October,  18  ; November,  8 ; December,  4 ; total,  110. 

Much  difference  of  opinion  existed  as  to  the  nature  of  the  disorder,  which  prevailed  so  exten- 
sively in  some  portions  of  the  city  as  to  be  with  propriety  called  epidemic.  The  rate  of  mortality  from 
the  disease  did  not  exceed  two  to  three  per  cent , and  the  total  estimated  cases  for  July  and  August 
would  therefore  be  almost  one  thousand.  The  disease  received  various  names,  as  typho-malarial 
fever,  typhoid  fever,  continued  fever  and  fievre  muqueuse. 

The  President  of  the  Board  of  Health  states  that  of  the  disease  “ very  few  cases  and  no  deaths 
i occurred  at  the  Charity  Hospital.”  This  statement  is  incorrect,  as  nine  cases,  with  five  deaths,  of 
typho-malarial  fever,  and  five  cases  and  four  deaths  of  typhoid  fever,  were  reported  and  published 
in  the  “ Report  of  the  Board  of  Administrators  of  the  Charity  Hospital  for  1874.” 

A portion  of  these  cases  were  without  doubt  genuine  typhoid  fever.  I observed  in  two  fatal 
cases  hemorrhage  from  the  bowels,  and  in  one  case,  in  which  a post-mortem  was  held,  the  glands  of 
Peyer  presented  the  characteristic  lesions  of  genuine  typhoid  fever. 

Dr.  D’Aquin,  from  the  records  of  thirty-two  cases,  regarded  the  disease  as  enteric  fever.  His 
notes  show  the  average  duration  of  the  disease  to  have  been  twenty-one  days.  Diarrhoea  pres- 
■ ent  in  many  cases.  No  hemorrhage  from  the  bowels.  Epistaxis  frequent  about  fifth  or  sixth  day 
in  light  cases.  Relapses  of  severity  occurred  in  four  of  the  thirty-two  cases.  Rose-colored  spots 
were  present  in  certain  of  the  cases.  The  disease  seemed  to  spread  from  member  to  member  of 
i families.  In  six  severe  typical  cases  the  march  of  the  temperature  corresponded  in  a marked 
i manner  with  the  typical  typhoid  fever  temperature  of  Wunderlich. 

The  heaviest  mortality  of  1874  occurred  in  the  months  of  July  (700)  and  August  (708).  In 
September  the  mortality  fell  to  440,  and  rose  again  to  626  in  October.  The  unusual  mortality  of 
'July  and  August  was  due,  in  part  at  least,  to  the  elevated  temperature,  or  so-called  heated  term, 
which  prevailed  in  all  sections  of  the  United  States,  affecting  the  north,  west  and  south  in  succes- 
. sion.  Two  cases  of  sunstroke  were  recorded  in  July  and  23  in  August;  total  for  the  year,  25. 

’I  j Congestion  of  the  brain  caused  214  deaths;  76,  or  almost  one-third,  occurred  in  the  month  of 
August.  Congestive  fever  caused  254  deaths,  one-third  of  which,  or  more  exactly  81,  occurred  in 


*“  Annual  Report  of  Board  of  Health,  1874,”  p.  25.  j-  Ibid,  p.  24,  p.  61. 


412 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


the  month  of  August.  Therefore,  180  deaths  out  of  a total  of  708  in  the  month  of  August,  were 
caused  by  sunstroke,  congestion  of  the  brain,  and  congestive  fever. 

The  heaviest  mortality  of  1874  appears  to  have  occurred  during  the  week  ending  Sunday, 
August  16th,  and  amounted  to  296,  when  in  ordinary  years,  free  from  epidemic  diseases,  the  mor- 
tality would  have  been  not  more  than  between  120  and  140.  This  frightful  mortality  resulted 
chiefly  from  the  excessive  heat,  and  to  this  cause  alone  may  be  attributed,  during  this  short  space 
of  time,  between  156  and  176  deaths.  The  deaths  during  the  week  ending  August  16th,  according 
to  ages,  were  : under  1 year,  33 ; 1 to  2 years,  17 ; 2 to  5 years,  19 ; 5 to  10  years,  9 ; 10  to  15  years, 

2 ; 15  to  20  years,  9 ; 20  to  25  years,  18 ; 25  to  30  years,  19  ; 30  to  40  years,  58 ; 40  to  50  years,  34; 

50  to  60  years,  40 ; 00  to  70  years,  19  ; 70  to  80  years,  10  ; 80  to  90  years,  1 ; 90  to  100  years,  0; 
unknown,  8. 

YELLOW  FEVER,  1875. 

Total  deaths  in  New  Orleans,  1875,  from  all  causes,  less  still-born,  6117,  including  still-born 
(418),  6535. 

Yellow  fever  caused  61  deaths,  distributed  as  follows:  August,  5;  September,  24;  October,  20;  ! 
November,  9 ; December,  3.  The  different  forms  of  fever  caused  the  following  deaths:  Continued, 

2;  congestive,  187;  gastric,  3;  intermittent,  30;  malarial,  116;  nervous,  4;  puerperal,  19;  remit-  ! 
tent,  36;  scarlet,  144;  typhoid,  57;  typho-malarial,  14;  typhus,  2;  yellow,  61;  total  deaths  by  1 
fevers,  685  ; consumption,  799;  inflammation  of  lungs,  261;  pneumonia,  30;  cholera  sporadica, 

4;  infantum,  100;  morbus,  12;  diarrhoea,  167;  dysentery,  126;  inflammation  of  bowels,  104;  \ 
total  diseases  of  bowels,  513. 

Smallpox  caused  342  deaths,  as  follows:  January,  cases  93,  deaths  38;  February,  cases  152,  j 
deaths  55;  March,  cases  240,  deaths  98;  April,  132  cases,  44  deaths;  May,  cases  90,  deaths  30;  ] 
June,  cases  83,  deaths  31;  July,  cases  56,  deaths  21;  August,  cases  39,  deaths  16;  September, 
cases  7,  deaths  4;  October,  cases  7,  deaths  4;  November,  cases  19,  deaths  6;  December,  cases  17,  I 
deaths  5;  total  cases,  935;  males,  496;  females,  429;  not  stated,  10;  white,  415;  colored,  477;  ‘ 
not  stated,  43;  total  deaths,  342;  white,  131;  colored,  201;  not  stated,  10. 

As  in  the  preceding  years,  the  highest  mortality  fell  upon  the  colored  race,  and  this  decreased  j 
during  the  progress  of  the  year,  with  the  elevation  of  the  temperature.  The  decrease  was  clearly  1 
referable  to  climatic  causes  and  not  to  any  measures  of  disinfection. 

Scarlet  fever  caused,  during  1875,  a larger  mortality  than  in  the  nine  preceding  years;  thus,  r 
deaths’from  scarlet  fever,  1867,  24;  1868,  14;  1869,  13;  1870,  44;  1871,  5;  1872,  3;  1873,  8;  ] 
1874,4;  1875,144.  In  1875  the  monthly  deaths  from  scarlet  fever  were  as  follows  : January,  1;  | 
February,  1;  March,  2;  April,  2;  May,  2;  June,  8;  July,  20;  August,  21;  September,  28;  j 
October,  18;  November,  20;  December  21;  total,  144. 

The  death  rate  from  malarial  fevers  and  the  general  death  rate  was  lower  in,  1875  than  in 
1874.  In  the  latter  year,  1874,  the  total  death  rate  per  1000  was  32.73;  whites,  28.06;  colored,  j 
45.53;  while  in  1875  the  death  rate  was:  colored,  39.69 ; white,  25.45 ; and  death  rate  for  whole  1 
population,  29.13.  The  death  rate  is  based  upon  an  estimate  of  210,000  inhabitants,  155,000  ] 
whites  and  55,000  colored. 

In  1875  yellow  fever  appeared  in  Louisiana  at  three  points ; in  the  city  of  New  Orleans,  at  Cous-  J 
hatta,  on  Red  river,  and  at  Port  Eads.  The  total  number  of  cases  recorded  in  New  Orleans  during 
the  year  was  100,  of  which  two  came  from  Pascagoula  and  three  from  Port  Eads.  Key  West,  j 
Barancas  and  Parvill’s  Point,  Florida  and  Scranton,  Pascagoula  and  Moss  Point,  Mississippi,  suf-  1 
fered  with  yellow  fever.  1 

The  total  recorded  cases  in  New  Orleans  in  1875,  excluding  those  from  Pascagoula,  Port  Eads,  { 
was  95.  The  mortality  was  heavy,  reaching  61  per  cent.,  being  a total  of  61  deaths. 

The  disease  first  appeared  in  the  Second  District,  and  was  almost  entirely  confined  to  a locality 
four  blocks  by  five.  This  was  the  principal  focus  of  infection  of  the  summer.  In  this  locality  the 
first  case  occurred  August  8th,  and  the  last  one  November  28th,  the  total  number  of  undoubted  i 
cases  being  41.  “ Disinfection  of  streets  was  thoroughly  effected,  but  that  of  yards  and  habita- 

tions, owing  to  very  great  opposition,  was  so  far  interfered  with  as  to  render  the  immediate  arrest 
of  the  fever  impossible,  even  granting  that  the  process  of  disinfection  is  able  to  promptly  and 
entirely  destroy  yellow  fever  poison.”  • 

The  following  is  the  monthly  record  of  cases  and  deaths  from  yellow  fever  in  1875:  August, 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


413 


eases  10,  deaths  8 ; September,  cases  59,  deaths  28  ; October,  cases  20,  deaths  15 ; November,  cases  8, 
i deaths  8;  December,  cases  3,  deaths  2. 

In  the  Charity  Hospital  16  cases  were  treated,  with  11  deaths.  Total  admissions  to  Charity  Hos- 
pital, 4845,  deaths,  753.  Of  the  admissions  2634  were  foreigners  and  2198  natives  of  the  United 
States,  including  816  natives  of  Louisiana.  The  cases  and  deaths  from  fevers  were  as  follows: 
Malarial,  731  cases,  67  deaths:  intermittent,  695  cases,  5 deaths;  remittent,  84  cases,  1 death; 
i typho-malarial,  11  cases,  5 deaths;  typhus,  4 cases,  1 death;  congestive,  4 cases,  2 deaths  ; bilious 
remittent,  4 cases;  scarlet,  1 case;  catarrhal,  1 case;  pernicious,  7 cases,  7 deaths;  bilious,  2 cases, 
I 2 deaths:  yellow,  16  cases,  11  deaths;  diarrhoea,  cases  282,  deaths  75;  dysentery,  cases  158, 
. deaths  38:  phthisis  pulmonalis,  cases  263,  deaths  151;  pneumonia,  cases  113,  deaths  37. 

From  the  reports  of  Dr.  S.  S.  Herrick,  Sanitary  Inspector,  First  District,  we  gather  that  21 
i cases  properly  belong  to  the  First  District  for  1875,  though  six  more  were  treated  at  the  Charity 
Hospital  and  the  Touro  Infirmary.  Only  two  foci  of  infection  seem  to  have  been  established.  These 
were  in  the  neighborhood  of  the  saw  mill  on  the  New  Canal,  between  Galaxy  and  Miro  streets,  and 
at  the  head  of  the  New  Basin.  The  source  of  infection  for  neither  locality  could  bo  traced.  The 
I earliest  cases  at  the  first  spot  died  before  they  were  recognized  as  yellow  fever,  and  of  the  whole 
: family  not  one  was  left  to  throw  any  light  on  the  origin  of  their  sickness.  Two  other  cases 
i sickened  while  this  locality  was  undergoing  disinfection  for  the  first  four.  “ After  their  termina- 
I tion,  disinfection  was  repeated,  and  no  more  cases  followed.” 

At  the  head  of  the  basin  four  cases  occurred  during  a period  of  time  much  more  extended  than 
at  the  other  place.  The  first  sickened  between  August  2Sth  and  29th,  and  disinfection  followed 
| September  2d.  The  second  sickened  September  5th,  followed  by  disinfection  on  the  9th  and  10th. 

!The  other  cases  sickened  on  September  22d  and  27th,  respectively. 

In  the  Second  District  the  deaths  from  yellow  fever  in  1875  were  as  follows  : August,  4;  Sep- 
tember, 7 ; October,  13;  November,  4;  December,  1 ; total,  29;  6 cases  in  August;  22  cases  occur- 
ring during  September;  14  in  October;  4 in  November,  1 in  December;  total,  47  cases. 

In  the  Third  District,  8 cases  of  yellow  fever  occurred  : August,  1;  September,  2;  October,  5. 
During  the  yellow  fever  of  1875,  the  same  liberal  and  lavish  use  of  carbolic  acid  was  made 
both  within  and  without  the  houses,  and  each  case,  as  it  occurred,  was  circumscribed  by  a large 
area,  saturated  with  a solution  of  carbolic  acid,  upon  the  theory  that  the  germ  of  yellow  fever 
traveled  slowly  along  the  ground.  All  the  alleys,  yards  and  empty  lots  of  every  square  upon 
which  a case  of  yellow  fever  was  reported  were  sprinkled  with  crude  carbolic  acid  by  means  of 
hand  pots  and  sprinkling  carts.  About  70  gallons  of  crude  carbolic  aeid  were  used  per  square, 
i In  a similar  manner  the  cross  streets  were  treated  with  carbolic  acid  at  a rate  of  about  15  gallons 
per  100  yards  length  of  street.  We  have  no  accurate  estimate  of  the  amount  of  carbolic  acid  thus 

I used,  but  thousands  and  tens  of  thousands  of  gallons  were  used  in  1870,  1871,  1872,  1873,  1874 
and  1875. 

YELLOW  FEVER,  1S76. 

The  total  deaths  from  all  causes  in  New  Orleans  during  1876,  exclusive  of  still-born,  was  6257; 

’ inclusive  of  still-born,  6685. 

The  monthly  deaths  were  as  follows:  January,  436;  February,  460;  March,  559;  April,  447 ; 
( May,  601;  June,  653;  July,  536;  August,  469;  September,  503;  October,  477;  November,  524; 

3 December,  592. 

Total  deaths  from  fevers,  1876;  bilious,  7;  catarrhal,  30;  congestive,  129;  gastric,  11;  inter- 
1 mittent,  33;  malarial,  144;  nervous,  1 ; pernicious,  33 ; puerperal,  18 ; remittent,  49;  scarlet, 
3 123;  typhoid,  53;  typho-malarial,  14;  typhus,  2;  yellow,  42.  Total  deaths  by  fevers,  689. 

Smallpox,  586  cases,  232  deaths.  The  cases  of  smallpox  occurred  as  follows:  January,  39; 
i February,  69;  March,  44;  April,  63;  May,  31;  June,  22;  July,  22;  August,  8;  September,  8; 
5 October,  31;  November,  82;  December,  187.  Total,  586.  It  will  be  observed  that,  as  in  preced- 
ing years,  the  smallpox  was  most  destructive  and  prevailed  to  the  greatest  extent  during  the  cold 
Q months  and  decreased  to  a great  extent  during  the  heat  of  summer,  thus  manifesting  a directly 
q opposite  relation  to  yellow  fever.  Apparently  a certain  degree  of  cold  concentrates  and  intensifies 
< the  smallpox  poison,  while  a certain  degree  of  heat  dissipates  and  destroys  it.  The  yellow  fever 
1 poison,  on  the  other  hand,  is  developed  and  spreads  only  at  elevated  and  tropical  temperatures, 
i and  is  arrested  by  cold.  These  facts  indicate  that  both  diseases  are  caused  by  organic  poisons  of 
f definite  chemical  constitutions  and  relations. 


414 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Deaths  in  1876  from  diseases  of  the  bowels:  Diarrhoea,  153;  dysentery,  132;  cholera,  9; 
cholera  infantum,  73 ; cholera-morbus,  13 ; inflammation  of  bowels,  71.  Total  deaths  from  bowel 
affections,  451. 

Total  deaths  from  consumption,  871. 

Yellow  fever  prevailed  to  a limited  extent,  and  was  confined  chiefly  to  the  Fourth  District. 

Total  cases  of  yellow  fever  in  the  entire  city,  96;  total  deaths  from  yellow  fever,  42. 

Total  admissions  to  Charity  Hospital  1876,  5690;  total  deaths,  742.  Of  the  admissions  2091 
were  foreigners,  2684  natives  of  the  United  States,  and  of  these  latter,  1015  were  natives  of  Louisi- 
ana. The  following  is  the  record  of  the  cases  of  deaths  from  the  various  forms  of  fever  in  the 
Charity  Hospital  during  1876.  Fever,  intermittent,  cases  136;  malarial,  cases  1161,  deaths  92; 
bilious,  case  1 ; bilious  remittent,  100  cases,  2 deaths;  remittent,  11  cases,  5 deaths;  malarial, 
chronic,  3 cases;  typho-malarial,  5 cases,  2 deaths;  dengue,  2 cases;  bilious,  17  cases;  continued, 
2 cases,  1 death;  typhoid,  9 cases,  4 deaths;  pernicious,  11  cases,  8 deaths;  catarrhal,  1 case; 
congestion,  3 cases,  3 deaths ; puerperal,  4 cases,  4 deaths ; yellow,  3 cases,  2 deaths ; enteric,  1 
case,  1 death;  rheumatic,  1 case;  rubeola,  124  cases;  malarial  haematuria,  2 cases.  Phthisis  pul- 
monalis,  cases  307,  deaths  128;  pneumonia,  120  cases,  49  deaths;  diarrhoea,  354  cases,  60  deaths; 
dysentery,  160  cases,  31  deaths. 

In  1876,  the  first  case  of  yellow  fever  officially  reported  to  Dr.  J.  B.  Gaudet,  President  of  the 
Board  of  Health,  occurred  on  the  11th  of  August,  on  Tchoupitoulas  street,  between  First  and  Sec- 
ond streets,  and  died  with  black  vomit  August  17th,  at  24  Eighth  street.  Anna  Maria  Yalender, 
aged  nineteen;  native  of  Germany;  in  New  Orleans  eighteen  months.  When  taken  ill  was  resid- 
ing as  a servant  in  the  family  of  Ambrose  Leitz,  on  Tchoupitoulas  street,  lake  side,  between  First 
and  Second  streets;  removed  second  day  of  illness  to  24  Eighth  street  ; died  Thursday  17th,  at  five 
o’clock  p.  m.  The  attending  physician,  Dr.  Joseph  Schmittle,  and  the  consulting  physicians,  Drs. 
F.  Loeber,  S.  S.  Wood,  F.  B.  Gaudet,  Charles  Faget,  Sr.,  A.  C.  Gaudet,  and  Joseph  Holt,  pro- 
nounced it  a genuine  case  of  yellow  fever. 

On  Wednesday  evening,  the  16th,  all  the  premises  in  the  square  bounded  by  Tchoupitoulas, 
Fulton,  First  and  Second  streets  were  thoroughly  sprinkled  with  refined  carbolic  acid,  Calvert’s 
No.  5,  in  solution,  one  part  of  acid  to  fifty  of  water.  The  banquettes  were  sprinkled  with  the  same. 
The  boundary  streets,  particularly  the  gutters,  were  sprinkled  with  the  crude  carbolic  acid,  one 
barrel  being  used.  On  the  evening  of  the  18th,  immediately  after  the  funeral,  the  rooms  and 
premises  of  No.  24  Eighth  street  were  sprinkled  with  the  pure  acid  solution.  This  method  of  dis- 
infection was  extended  to  all  the  premises  in  the  square  bounded  by  Tchoupitoulas,  Fulton,  Eighth 
and  Ninth  streets,  and  also  on  the  square  bounded  by  Tchoupitoulas,  Fulton,  Seventh  and  Eighth 
streets.  The  banquettes  were  sprinkled  with  the  pure  acid  solution,  and  a line  of  crude  carbolic 
acid  extended  through  the  boundary  streets.  Two  barrels  of  the  crude  acid  were  used.  The  fol- 
lowing day  Dr.  Le  Monnier  visited  the  house  24  Eighth  street,  and  thoroughly  disinfected  the 
bedding,  clothes  and  furniture  of  the  deceased. 

Careful  and  repeated  investigation  by  the  President  of  the  Board  of  Health,  Dr.  Gaudet,  by 
Dr.  Le  Monnier,  Secretary  of  the  Board  of  Health,  by  Dr.  Joseph  Holt,  Sanitary  Inspector  of  the 
Fourth  District,  and  by  the  sanitary  officers,  failed  to  discover  the  slightest  clue  to  foreign  infec- 
tion from  any  ship,  person  or  material. 

Case  ii. — Male,  aged  nineteen  years;  native  of  France,  resident  of  New  Orleans  eighteen 
months;  attacked  1st  of  September,  on  Annunciation  street,  between  Louisiana  avenue  and  Dela- 
chaise  street ; died  with  black  vomit  September  6th. 

Case  hi. — F.  E.,  age  seven  years;  native  of  Tennessee,  in  New  Orleans  three  years;  residence 
125£  Philip  street,  lower  side,  between  Annunciation  and  Laurel  streets.  Taken  sick  SeptemDOT 
1st.  Delirium,  jaundice  and  black  vomit  on  the  fourth  day;  child  recovered.  Caso  not  reported 
until  the  subsequent  prevalence  of  yellow  fever  confirmed  the  diagnosis  of  the  attendant  physician, 
Dr.  Mitchell.  Cases  occurred  in  the  same  house:  on  September  7th  (Mr.  J.  C.  E„  aged  thirty; 
native  of  Germany;  in  New  Orleans  three  years;  recovered).  Mr.  E.,  twenty-nino  years;  native 
of  Virginia;  in  New  Orleans  three  years;  September  7th  ; recovered.  G.  E.,  aged  six  years;  native 
of  Tennessee;  in  New  Orleans  throe  years;  September  11th;  recovered.  J.  C.  Ep,  age  four  years; 
native  of  Tennessee;  in  New  Orleans  three  years;  September  13th;  recovered. 

Case  iv. — K.  S.,  age  thirteen  ; nativo  of  Honduras;  in  New  Orleans  twelvemonths;  Philip 
and  Annunciation  streets  ; taken  sick  September  5th  ; black  vomit  8th  ; died  10th.  Disinfection 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  415 


of  premises  was  attempted  the  following  morning,  but  was  prevented  by  the  illness  of  two  of  the 
family.  These  recovered  without  manifesting  symptoms  sufficient  to  confirm  a diagnosis.  Within 
one  square  radius  of  this  house  thirty-three  of  the  recorded  cases  took  the  disease.  Fifteen  of 
these  were  fatal. 

Case  v. — A.  B.  F.,  age  three  years;  native  of  New  Orleans;  taken  sick  September  5th  at  120 
Jackson  street,  between  Annunciation  and  Laurel  streets;  died  September  10th,  with  jaundice  and 
black  vomit.  Case  not  reported  to  Board  of  Health  until  September  28th. 

Case  vi. — Mrs.  D.,  age  twenty-three ; native  of  Michigan  ; in  New  Orleans  four  months.  Has 
resided  in  Third  District  until  three  weeks  prior  to  illness,  when  she  removed  to  104  Jackson  street, 
between  Chippewa  and  Annunciation.  Taken  ill  September  5th,  Dr.  Thomas  Layton  attending. 
“ Her  case  presented  all  the  prominent  features  of  yellow  fever,  such  as  a fever  of  one  paroxysm, 
and  of  seventy  hours’  duration  ; general  redness  of  the  skin,  with  appearance  of  oedematous  thick- 
ening, as  the  rash  of  scarlatina;  a maintained  temperature  of  103°  to  104°;  great  dullness  of  the 
' sensorium  and  delirium.  This  stage  was  terminated  by  a sudden  fall  of  temperature,  prostration, 
slow  pulse.  Capillary  stasis,  yellow,  but  not  cyanotic  hue  of  skin,  eyes  yellow,  albumen  in  urine, 
and  on  the  fifth  day  copious  black  vomit  frequently  ejected.  Being  eight  months  pregnant,  she 
was  delivered  of  a still-born  child  on  the  ninth  day  of  her  illness.  Recovered.  She  came  near 
flooding  to  death  sixty  hours  after  delivery.” 

Case  vii. , age  sixteen,  male  ; native  of  New  Orleans ; corner  Orange  and  St.  Thomas 

streets;  taken  sick  September  7th  ; died  September  12th. 

Case  viii. — Mr.  J.  C.  E.,  aged  thirty;  native  of  Germany;  in  New  Orleans  three  years;  125J 
Philip  street ; taken  sick  September  7th;  recovered. 

Case  ix. — Mrs.  E.,  age  twenty-nine;  native  of  Virginia;  125 J Philip  street;  September  7th; 
recovered. 

CAse  x. — C.,  age  twenty-eight,  male;  native  of  England;  in  New  Orleans  three  years;  173 
Rousseau  street,  between  Soraparu  and  Firststreets ; taken  sick  September  8th;  black  vomit  and 
j death  September  11th.  Policeman.  Premises  disinfected. 

Case  xi. — M.  M.,  female,  native  of  Ireland ; in  New  Orleans  three  years ; 20  Josephine  street, 

• between  Tchoupitoulas  and  Rousseau;  Sept.  8th;  case  reported  Sept.  11th;  recovered. 

Case  xii. — A.  R.,  colored,  female,  age  twelve;  native  of  Arkansas;  in  New  Orleans  seven 
i years;  residence  45  Polymnia  street ; servant  in  family  of  Mr.  E.  (Case  8),  125£  Philip  street; 
taken  sick  Sept.  8th  ; recovered. 

Case  xiii. — C.  H.,  female,  age  ten;  native  of  Massachusetts;  in  New  Orleans  nine  years;  122 
Philip  street,  corner  Annunciation ; Sept.  9th  ; case  reported  Sept.  21st ; recovered.  Fifteen  days 
previous  to  illness  the  family  had  returned  from  a tour  through  the  Northern  States. 

Case  xiv. — G.  E.,  age  six;  native  of  Tennessee;  in  New  Orleans  three  years;  125£  Philip 
street;  taken  ill  Sept.  11th;  recovered. 

Case  xv. — M.  J.,  age  eight;  native  of  New  Orleans;  in  New  Orleans  four  months  after 
i residing  in  St.  Louis  four  years;  died  Sept.  18th ; disinfection  after  funeral ; residence  135  Jack- 
i son  street,  between  Annunciation  and  Laurel. 

Case  xvi. — S.  W.,  colored,  female,  age  fifty;  native  of  Virginia;  in  New  Orleans  five  years; 
sick  nurse  in  family  of  Mr.  E.  (125£  Philip  street,  Case  8) ; residence  72  Union  street;  Sept.  12th; 
i on  the  third  and  fourth  days  vomited  blood ; recovered. 

Case  xvii. — J.  G.  W.,  male,  age  thirty-three;  native  of  Glasgow;  in  New  Orleans,  three 
' years;  166  Jackson  street;  taken  sick  Sept.  12th;  died  Sept.  18th;  disinfection  Sept.  19th. 

Case  xviii. — J.  C.  E.,  age  four  years;  native  of  Tennessee;  in  New  Orleans  three  years;  125J 
Philip  street;  Sept.  13th;  recovered. 

Case  xix.— -Sister  E.,  age  thirty-eight;  native  of  Germany;  in  New  Orleans  three  months; 

: St.  Joseph’s  Asylum,  Josephine  street,  corner  Laurel;  resided  in  Asylum  as  cloistered  nun;  taken 
' sick  Sept.  13th  ; black  vomit  on  third  day;  reported  18th  ; died  Sept.  24th. 

Case  xx. — Mrs.  J.  E.W.,  age  thirty-six ; native  of  Pennsylvania;  in  Now  Orleans  five  years;  473 
Annunciation  street, between  Philip  and  Firststreets;  taken  sick  Sept.  14th  ; died  Sept.  21st;  black 
l vomit,  suppression  of  urine.  At  this  time  the  sanitary  force  of  the  Fourth  District,  under  the 
direction  of  Dr.  Holt,  was  engaged  in  the  general  disinfection  of  the  infected  district. 

Case  xxi. — F.,  age  18  years  ; native  of  Ireland ; in  New  Orleans  three  years;  58  Orange  street; 

' Sept.  14th ; recovered. 


41G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Case  xxii. — S.  E.,  one  year;  native  of  New  Orleans;  125J  Philip  street;  Sept.  15th;  recovered. 

Case  xxiii. — Sister  Francis,  age  twenty-one;  native  of  Michigan;  came  to  New  Orleans  Octo- 
ber, 1874;  has  resided  as  a cloistered  nun  at  St.  Joseph’s  Asylum;  taken  siek  Sept.  15th; 
reported  Sept.  18th;  recovered.  (Josephine  and  Laurel  streets.) 

Case  xxiv. — Sister  Alfreda,  age  thirty ; native  of  Prussia;  came  to  New  Orleans  1870  ; has  ] 
resided  since  as  a cloistered  nun  in  St.  Joseph’s  Asylum,  Josephine  and  Laurel  streets;  taken  sick 
Sept.  10th ; reported  Sept.  18th ; recovered. 

Case  xxv. — M.  W.,  female,  age  seven;  native  of  New  Orleans;  191  Josephine  street;  Sept,  j 
16th  ; recovered. 

Case  xxvi. — A.  W.,  female,  age  four;  native  of  St.  Louis;  in  New  Orleans  two  months;  161 
Laurel  street ; Sept.  16th;  albumen  in  urine,  black  vomit;  recovered. 

Case  xxvii. — Sister  B.,  age  twenty-five;  native  of  New  York;  in  New  Orleans  ten  months;  | 
St.  Joseph's  Asylum,  Josephine  and  Laurel  streets;  suppression  of  urine;  black  vomit;  taken 
sick  Sept.  17th;  died  Sept.  21st. 

Dr.  Thomas  Layton,  Physician  of  St.  Joseph’s  Hospital,  states  that:  “In  the  cases  of  thesis-  1 
ters  the  usual  pains  in  the  head,  back  and  limbs  were  present.  The  fever  was  one  of  unbroken 
paroxysms,  with  a decided  typhoid  tendency  in  the  cases  which  recovered.  In  these  the  patients  1 
continued  having  fever,  as  observed  by  the  thermometer,  for  a great  many  days.  This  secondary  ’ 
fever  was  of  a low  grade,  and  at  the  time  the  pulse  was  at  or  about  the  normal  standard.  All  | 
have  resembled  each  other  strikingly  in  the  general  symptoms  and  appearance  at  the  outset.” 

The  disinfection  of  St.  Joseph’s  Asylum,  corner  of  Laurel  and  Josephine  streets,  was  com-  1 
menced  by  the  sisters,  directed  by  Dr.  Layton,  on  Sunday,  Sept.  17th.  A solution  of  the  pure  I 
carbolic  acid  was  used.  All  bedding  and  clothing  removed  from  the  siek  were  wet  with  it;  also  I 
the  floors  of  rooms  and  balls,  the  sewers  and  privies.  The  ejecta  of  patients  were  carbolized  and  1 
buried  in  the  yard,  to  avoid  the  possibility  of  infecting  the  privies.  On  the  20th  of  the  month  all  | 
of  the  floors  of  the  building,  privies,  drains  and  yards  were  thoroughly  treated  with  the  pure  car-  | 
bolic  acid  solution,  one  part  to  forty,  by  the  sanitary  officers;  this  was  repeated  on  the  25th.  | 
Living  on  the  premises  of  this  asylum  are  210  whites;  25  of  these  are  cloistered  nuns.  Number 
of  persons  acclimated  by  having  had  yellow  fever,  six.  No  ease  of  yellow  fever  occurred  in  this  # 
institution  after  the  17th,  and  this  result  was  referred  by  the  physician  in  charge,  the  Sanitary  | 
Inspector  of  the  Fourth  District  and  the  Board  of  Health,  to  the  thorough  disinfection  of  this 
institution. 

Case  xxviii. — Mrs.  S.,  age  thirty-five;  native  of  England;  in  New  Orleans  three  years;  418  1 
Prytania  street,  between  Seventh  and  Eighth;  Sept.  17th;  died  Sept.  23d. 

Case  xxix. — J.  R.  M.,  sailor,  ship  “Belgravia,”  age  thirty-five;  native  of  England;  had  been 
living  on  shipboard,  but  had  visited  the  infected  district;  taken  siek  Sept.  17th ; black  vomit;  1 
died  Sept.  20th.  The  ship  “ Belgravia  ” arrived,  direct  from  Liverpool,  August  20th,  with  cargo  of 
bricks  and  salt;  lay  at  the  foot  of  Second  street;  ship  thoroughly  disinfected. 

Case  xxx. — S.  D.,  female,  age  eight;  native  of  New  Orleans;  71  Laurel  street,  between  j 
Josephine  and  St.  Andrew;  Sept.  17th:  high  fever;  one  paroxysm  of  eighty  hours;  temperature 
106°,  pulse  136 ; albumen  in  urine;  recovered;  reported  23d. 

Case  xxxi. — M.  H.,  female,  age  seven  years;  native  of  New  Orleans;  122  Philip  street;! 
died  Sept.  22d. 

Case  xxxii. — G.  E.  W.,  age  thirty-six ; native  of  New  York ; in  New  Orleans  seven  years ; 137  1 
Laurel  street,  Sept.  18th;  died  Sept.  21st. 

Case  xxxiii. — Mrs.  E.  R.,  age  twenty-five;  native  of  Texas;  in  New  Orleans  some  months; 
505  Annunciation  street ; Sept  18th ; died  23d.  An  intense  fever  of  eighty  hours’ duration.  On 
third  day  of  attack  delivered  of  a seven  months’  foetus. 

Case  xxxiv. — Mr.  G.  C.  R.,  age  twenty-two  years;  native  of  Ohio;  in  Now  Orleans  two  ( 
weeks;  505  Annunciation  street,  between  First  and  Second.  “ Was  taken  sick  September  19th, 
during  the  night;  chill  followed  by  fever  of  one  paroxysm  of  forty-eight  hours  and  very  intense. 
This  stage  was  characterized  by  those  common  symptoms,  the  exanthematous  redness  of  the  skin,  j 
bloodshot  eyes,  red  tongue  and  gums,  and  great  irritability  of  the  stomach.  On  the  third  day  j 
the  dangerous  symptoms  were  greatly  intensified  by  mental  shock  occasioned  by  startling  bad  news 
told  him,  and  also  by  getting  out  of  bed.  He  rapidly  sank  into  an  adynamic  state,  presenting 
the  nervous  depression  and  irritability  of  typhoid;  extreme  yellowness  of  skin  and  eyes;  urine 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  417 


solidly  albuminous  on  test,  with  casts;  occasional  black  vomit;  during  the  last  two  days  incessant 
hiccough.  Died  at  eight  o’clock  A.  m.,  Oct.  4th,  after  an  illness  of  fifteen  days.” 

Case  xxxv. — A.  D.,  age  fourteen  ;. native  of  Arkansas;  in  New  Orleans  nine  months;  inmate 
Jewish  Orphans’  Home,  Jackson  street,  between  Rousseau  and  Chippeway;  Sept.  21st;  fever  sixty 
hours ; during  eighteen  hours  temperature  104^°;  after  bloodletting  by  cut  cups  fell  to  102°,  with 
decline  of  fever  on  third  day;  pulse  became  slow  and  feeble.  This  stage  was  followed  by  oppression 
over  epigastrium,  vomiting  of  clear  blood ; urine  albuminous  ; catamenia  returned ; recovered 
under  care  of  Dr.  F.  Locker  at  the  First  Infirmary.* 

Case  xxxvi. — G.,  female,  aged  twenty-four;  native  of  Louisiana;  in  New  Orleans  ten  years; 
130  Philip  street,  between  Annunciation  and  Laurel  streets;  September  22d;  recovered. 

Case  xxxvii. — W.  C.,  three  years;  native  of  Mississippi;  in  New  Orleans  two  years;  502 
Annunciation  street;  September  22d ; died  26th. 

Case  xxxviii. — John  Maxwell,  aged  thirty  years;  native  of  Alabama;  in  New  Orleans  four 
days;  residence,  429  Annunciation  street,  between  Jackson  and  Philip  streets.  Taken  ill  Sep- 
tember 23d;  Dr.  Ason  the  attending  physician.  The  clinical  signs  were  those  of  a severe  case  of 
yellow  fever;  a period  of  malaria  ending  in  rigors,  superseded  by  a fever  of  many  hours’  dura- 
tion ; hiccough  and  cramp  in  stomach  twelve  hours  before  death.  Post-mortem  changes  rapid. 
Died  September  29th.  It  is  evident  that  in  the  preceding  case  the  period  of  incubation  of  the 
yellow  fever  poison  could  not  have  exceeded  four  days.  We  also  observe  the  promptness  with 
which  a stranger  was  attacked  when  coming  into  the  infected  district,  and  yet,  when  strangers 
remained  in  the  central  portion  of  the  city  and  did  not  visit  the  infected  district,  they  escaped 
entirely.  A refugee  from  Savannah,  Mr.  C.  Ring,  who  came  to  New  Orleans  with  the  intention 
of  opening  a branch  of  his  house  in  the  cotton  business,  placed  himself  under  my  care  and 
remained  during  September  and  October  at  the  City  Hotel,  and,  by  my  advice,  avoided  the  Fourth 
District.  He  escaped.  The  cause  of  the  fever,  as  shown  by  the  brief  record  of  the  preceding  thirty- 
eight  cases,  was  circumscribed  in  its  action  and  the  spread  was  slow.  It  is  unnecessary,  as  we 
have  by  the  preceding  observations  established  the  local,  indigenous  origin  of  the  disease,  and  its 
slow  spread  and  marked  localization,  to  further  protract  the  examination  of  individual  cases,  and 
we  proceed  to  record  the  results  of  the  labors  of  the  Board  of  Health  to  confine  and  destroy  the 
disease  by  disinfection. 

Of  the  total  number  of  cases  occurring  in  the  entire  city  of  New  Orleans  during  the  summer 
and  fall  of  1876,  namely,  92,  more  than  two-thirds,  or  74,  occurred  in  the  Fourth  District.  Of 
these  74  cases  the  first  occurred  in  August ; 53  in  September,  and  20  in  October.  Total  number 
of  cases  in  Fourth  District,  74;  whites,  71;  colored,  3;  natives  of  foreign  countries  and  other 
States,  53;  natives  of  New  Orleans,  17;  of  Louisiana,  4;  number  of  deaths,  35.  Mortality  in 
Fourth  District  nearly  50  per  cent. 

We  are  indebted  to  Dr.  Joseph  Holt,  the  Sanitary  Inspector  of  the  Fourth  District,  for  a record 
of  the  efforts  of  the  Board  of  Health  to  control  the  disease  by  disinfection.  The  following  facts 
are  condensed  from  his  report  to  the  Board  of  Health.f 

The  first  case  in  1876  occurred  August  11th,  in  Tchoupitoulas  street,  between  First  and  Second 
streets.  Removed  to  24  Eighth  street,  between  Tchoupitoulas  and  Fulton,  where  she  died  on  the 
18th.  Careful  investigation  failed  to  connect  this  case  with  any  foreign  importation.  The  second 
case  was  attacked  September  3d,  at  125J  Philip  street.  Besides  the  difference  of  twenty-three  days 
in  the  appearance  of  these  cases,  there  had  been  no  communication,  and  between  them  were  five 
squares,  measured  diagonally.  These  squares  were  compactly  built,  and  many  of  the  inhabitants 
were  ascertained  to  be  wholly  unacclimated.  It  is  not  likely,  therefore,  that  the  disease  could 
have  spread  from  the  first  to  the  second  case  without  influencing  others  on  its  way.  It  is  more 
reasonable  to  believe  that  the  causes  of  infection  in  the  first  case  operated  independently  to  pro- 
duce it  in  the  second. 

In  the  immediate  neighborhood  of  125i  Philip  street,  corner  of  Annunciation,  the  disease 


*“  Cases  of  Yellow  Fever  in  New  Orleans  in  1876,  reported  to  the  Board  of  Health  by  Joseph  Holt, 
Sanitary  Inspector  of  Fourth  District,  New  Orleans.” 

f “ Cases  of  Yellow  Fever  in  New  Orleans  in  1876.”  New  Orleans  Medical  and  Surgical  Journal , Novem- 
ber, 1876,  pp.  337-368.  “ Analysis  of  the  Record  of  Yellow  Fever  in  New  Orleans  in  1876.”  New  Orleans 
Medical  and  Surgical  Journal,  January,  1877,  N.  S.,  Vol.  IV,  No.  4,  pp.  480-495. 

Vol.  IV— 27 


418 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


spread  with  some  degree  of  activity;  thus,  from  September  3d  to  September  7th  inclusive,  five 
cases  occurred,  and  all  within  a radius  of  two  hundred  feet.  Many  of  the  cases  occurring  about 
this  time  were  suspected,  but  recovering,  were  not  pronounced  yellow  fever,  because  of  their  lack- 
ing some  of  the  unquestionable  diagnostic  features  found  only  in  cases  usually  fatal.  It  was  not 
until  the  13th  of  September  that  the  Board  of  Health  had  alarming  evidence  of  the  epidemic 
tendency  of  the  disease,  as  shown  in  its  advance  toward  the  heart  of  the  city.  By  this  time  it  had 
passed  Constance  street  and  appeared  in  St.  Joseph’s  Asylum.  The  invasion  was  west  and  north- 
west, directly  in  the  face  of  a strong  and  constantly  prevailing  northwest  wind.  Within  a period 
of  eighteen  days  from  the  3d  of  September  it  had  spread  over  an  area  of  thirty-nine  squares,  :1 
densely  inhabited.  This  area  was  bounded  by  Magazine  street  and  the  river  front,  St.  Andrew 
and  Second  streets.  Of  the  74  cases  recorded,  60  were  within  these  limits.  Those  who  were 
stricken  elsewhere  in  the  Fourth  District  had  been  much  exposed  within  this  area.  This  rule 
prevailed,  with  three  exceptions  only,  to  the  end  of  the  season.  This  is  true,  also,  to  a great 
extent,  with  reference  to  the  18  cases  which  occurred  in  other  districts  of  the  city;  the  majority 
could  be  traced  to  the  infected  district. 

From  the  time  of  its  appearance,  on  the  3d  of  September,  to  the  last  case  on  the  record,  Octo- 
ber 13th,  the  visitation  continued  forty  days.  It  reached  its  height  in  twenty  days,  continued 
without  spreading  fifteen  days  and  declined  in  five  days. 

EFFORTS  OF  THE  BOARD  OF  HEALTH  TO  CONTROL  THE  YELLOW  FEVER  OF  1876,  IN  NEW  ORLEANS,  ; 

BY  THE  LIMITATION  AND  ACTUAL  DESTRUCTION  OF  ITS  CAUSE DISINFECTION. 

In  the  first  case,  as  we  have  seen,  the  disinfection  with  carbolic  acid  was  pushed  vigorously  and 
made  complete,  and  this  case  remained  isolated,  no  others  occurring  in  the  infected  or  adjoining 
squares. 

The  Cases  n,  in,  IV,  v and  vi,  in  the  second  focus  of  inspection,  appearing  eighteen  and  twenty 
days  later,  were  not  disinfected.  These  became  the  recognized  centre  of  the  epidemic,  and  from 
this  centre  the  disease  spread,  and  in  eighteen  days  had  invaded  39  squares,  besides  scattering 
cases  beyond  these  limits. 

A general  disinfection  was  commenced  on  the  night  of  September  22d.  Until  this  time,  all 
efforts  had  been  limited  to  the  disinfection  of  the  houses  and  premises  of  those  who  died.  On  the 
night  of  the  22d  a quadruple  cordon  of  the  pure  acid  solution,  one  part  to  forty  of  water,  was 
thrown  around  the  infected  area,  by  a thorough  sprinkling  of  the  boundary  streets  and  banquettes, 
a line  for  each  side  of  the  street,  and  in  the  same  way  for  the  next  inner  line  of  boundary  streets. 
The  object  of  this  was  to  put  a stop  to  the  march  of  the  pestilence  by  forming  around  the  infected 
locality  a barrier.  To  accomplish  this  required  235  gallons  of  the  pure  acid.  On  the  night  of  the 
23d  the  sixteen  streets  of  the  infected  area  were  similarly  disinfected.  From  this  date  the  daily 
occupation  of  the  sanitary  force  consisted  in  disinfecting  the  premises  of  the  squares  within  this 
area.  To  complete  five  squares  was  a day’s  work.  Whenever  a case  occurred  outside  of  these 
limits,  the  premises  of  the  square  and  of  the  one  opposite,  together  with  the  boundary  streets,  were 
disinfected.  Every  precaution  was  taken  to  avoid  bringing  the  acid  in  such  proximity  to  the 
patients  as  might  do  harm.  For  this  reason  the  premises  of  the  sick  and  those  adjoining,  one  on 
each  side,  were  not  touched.  A special  cordon  of  the  pure  solution  was  made  around  these.  On 
the  night  of  the  28th,  beginning  at  ten  o’clock,  the  sprinkling  carts  were  filled  with  the  crude 
carbolic  acid,  undiluted.  They  were  then  driven  through  a double  line  of  boundary  streets  of  the 
infected  area,  in  the  manner  already  described  for  the  night  of  the  22d.  The  following  night  a 
single  line  of  the  same  was  extended  through  the  sixteen  intersecting  streets.  This  was  done  as  a 
precautionary  measure,  inasmuch  as  a prevailing  strong  wind,  together  with  a burning  heat  of 
sun,  had  been  acting  to  dissipate  the  volatile  combination  of  cresylio  and  carbolic  acids,  here  spoken 
of  as  pure  acid,  distributed  on  the  nights  of  the  22d  and  23d.  The  crude  acid  was  used  in  order 
to  retain  these  more  volatile  constituents,  by  reason  of  their  combination  with  tar  and  the  heavier 
tar  products.  Theso  are,  no  doubt,  of  themselves,  powerful  disinfectants.  For  the  work  of  these 
two  nights  twenty  barrels  of  crude  acid  were  used.  Great  stress  was  laid  upon  the  assumed  limit- 
ing power  of  the  disinfectants.  The  area  infected  was  so  immense  as  not  to  permit  of  an  actual 
and  complete  disinfection  of  its  entiro  surface  with  any  amount  less  than  an  unlimited  supply  of 
the  acid.  To  disinfect  all  houses  and  premises  was  utterly  impossible.  The  most  that  could  be 
hoped  for  in  this  direction  was  to  apply  the  agent,  although,  at  best,  in  an  imperfect  and  unsatis- 
factory manner,  to  as  many  premises  as  we  were  able. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  419 

The  main  effort  of  Dr.  Joseph  Holt,  Sanitary  Inspector  of  the  Fourth  District,  was  expended 
upon  hedging  in  the  pestilence  by  carbolizing  the  streets  and  gutters — “just  as  would  be  done,  in 
its  own  proper  way,  in  the  case  of  a great  fire.” 

Except  where  some  one  had  died,  not  a private  house,  and  only  two-thirds  of  the  premises, 
were  disinfected — many  not  touched,  except  the  privies.  It  was  clearly  proved,  therefore,  that, 
even  after  our  best  efforts,  cases  would  continue  to  occur  in  this  locality.  From  tho  beginning  it 
was  the  established  rule  to  pay  particular  attention  to  the  carbolizing  of  privies.  Even  in  cases 
where  admittance  to  premises  was  otherwise  refused,  this  much  was  insisted  on ; second  to  this, 
the  carbolizing  of  street  gutters. 

RELATION  OF  DISINFECTION  TO  THE  SPREAD,  THE  FORMATION  AND  FINAL  CHECK  OF  THE  YELLOW 

FEVER  IN  NEW  ORLEANS,  IN  1876. 

There  were  seventy-four  recorded  cases.  During  the  twenty  days  from  Sept.  3d  to  the  night 
of  the  general  disinfection,  Sept.  23d,  there  occurred  35  cases.  During  the  twenty  days  following, 
to  October  13th,  the  date  of  the  last  case,  there  occurred  38  cases.  Seventeen  of  the  38  fell  sick 
during  the  first  five  days,  leaving  21  cases  for  the  remaining  fifteen  days.  Of  tho  38  cases,  11 
i occurred  outside  of  the  infected  districts.  Eight  of  these  had  been  nursing  the  sick  or  visiting 
socially  in  the  infected  area.  The  remaining  three  had  no  such  history,  but  had  evidently  con- 
i tracted  the  disease  outside  of  this  locality.  They  occurred  in  persons  who  had  been  in  close  prox- 
imity to  the  sick,  about  the  intersection  of  Eighth  and  Constance  streets,  who  had  been  infected 
in  the  diseased  locality.  This  appearance  gave  reason  to  fear  the  development  of  a new  centre 
of  infection.  This  new  area  comprised  the  sixteen  squares  bounded  by  Magazine  and  Chippewa, 
Washington  and  Ninth  streets.  . 

From  September  29th  to  October  5th,  the  disinfection  of  this  quarter  was  accomplished. 

With  reference  to  the  occurrence  of  the  disease  in  public  institutions  and  on  ships,  Dr.  Joseph 
Holt  records  the  following  important  facts  : — 

On  the  13th  of  September  a case  occurred  in  St.  Joseph’s  Asylum,  corner  of  Laurel  and  Jose- 
phine streets.  On  the  15th  another;  one  on  the  16th,  and  one  on  the  17th.  Two  of  these  were 
fatal.  On  the  17th  the  building  and  premises  were  disinfected  with  the  pure  acid  solution.  The 
same  was  applied  to  all  bedding  and  clothing  removed  from  the  patients.  This  was  accomplished 
by  the  sisters,  guided  by  Dr.  Layton.  Again,  on  the  20th,  by  the  sanitary  force,  the  yard,  sewers 
and  privies  were  thoroughly  treated  with  the  pure  acid,  one  part  to  fifty  of  water.  This  was 
repeated  on  the  25th.  (Other  public  institutions,  to  be  mentioned,  were  disinfected  in  the  same 
way.)  No  case  after  the  17th. 

Living  on  the  premises  were  210  white  persons,  of  whom  25  were  cloistered  nuns.  Of  the 
entire  number,  six  were  already  acclimated,  by  having  had  yellow  fever. 

In  the  Jewish  Orphans’  Home,  corner  Jackson  and  Chippewa  streets,  a case  occurred  Septem- 
ber 21st,  one  on  the  25th,  and  one  on  the  27th.  Two  of  these  were  fatal.  The  interior  of  this 
building  was  repeatedly  disinfected  by  the  inmates,  directed  by  Dr.  Locker,  in  the  manner  just 
mentioned.  The  premises,  including  yards,  drains  and  privies,  were  disinfected  by  tbe  sanitary 
force,  September  26th.  No  other  case  occurred.  Residing  on  the  premises  were  110  white  persons, 
of  whom  six  had  previously  had  yellow  fever. 

In  the  Convent  of  the  Sisters  of  Mercy,  on  St.  Andrew  street,  between  Constance  and  Maga- 
zine, a case  occurred  September  29th.  It  terminated  fatally.  This  institution  was  disinfected 
October  2d.  Living  on  the  premises  were  43  Sisters  of  Mercy,  19  emjiloy6s  and  70  orphans — -122 
persons — all  white.  Ten  of  them  had  already  had  yellow  fever.  In  the  immediate  neighborhood 
of  these  institutions  the  private  residences  invaded,  but  never  disinfected,  seemed  to  fare  differ- 
ently. The  disease,  in  many  instances,  attacked  in  succession  every  member  of  the  family  liable 
— frequently  three,  four,  and  as  many  as  eight. 

The  sailing  ship  “Belgravia”  arrived  direct  from  Liverpool  August  29th.  She  landed  about 
the  foot  of  Second  street,  where  she  remained  to  tho  present  time.  Tho  crew  wore  allowed  to  go 
on  shore  at  will.  One  of  the  sailors  was  taken  ill  aboard  ship  September  17th.  On  tho  20th  ho 
was  conveyed  to  the  Touro  Infirmary,  where  he  died  the  samo  day.  On  tho  20th  the  ship  was 
thoroughly  disinfected  with  carbolic  acid  and  chlorinated  lime.  The  bedding  and  clothes  of  the 
deceased  were  tied  in  a bundle,  weighted  with  stones,  and  sunk  in  the  river.  The  ship  was 
thoroughly  washed  throughout.  After  this  she  was  repeatedly  carbolized  and  cleansed.  During 
the  ten  days  following  the  death  of  this  case  the  crew  remained  closely  about  the  vessel.  After 


420 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


this  time  some  of  them  became  reckless,  and  frequented  the  places  in  the  infected  area,  where 
this  man  caught  the  disease.  Two  of  the  crew  fell  ill  of  the  disease  on  the  morning  of  October 
8th,  and  died  at  the  Touro  Infirmary,  one  on  the  12th  and  one  on  the  14th  inst.  The  command-  '■ 
ing  officer  predicted  the  illness  of  these  men,  in  a conversation  with  Dr.  Joseph  Holt,  a few  days  I 
before  they  were  taken,  because  of  their  foolhardiness.  Living  on  board,  officers  and  crew,  twenty 
men,  none  of  whom  had  over  been  exposed  to  yellow  fever. 

Just  astern  the  “ Belgravia  ” lay  the  sailing  ship  “Evangeline.”  Officers  and  crew  unaccli-  ' 
mated.  The  captain’s  wife  spent  a Sabbath  evening  with  a friend  living  in  the  infected  centre,  5 
October  11th.  She  was  taken  ill  the  following  evening  and  died,  having  thrown  up  black  vomit  : 
freely,  October  16th.  The  same  method  of  disinfection  was  pursued  as  with  the  “ Belgravia.”  No  1 
other  case  occurred. 

Dr.  Joseph  Holt  presents  the  following — 

RESUME. 

Total  number  of  cases : White,  71;  colored,  3 (74) ; natives  of  New  Orleans,  17 ; of  Louisiana, 

4;  of  other  States  and  countries,  53;  deaths,  35;  total  amount  of  disinfectants  used:  Pure  car-  I 
bolic  acid,  Calvert’s  No.  5,  19  barrels,  ranging  from  45  to  50  gallons  each  = about  912  gallons. 
Total  crude  carbolic  acid  compound,  40  barrels,  containing  45  gallons  each  = 1600  gallons.  Total 
areas  disinfected,  streets  and  promises  of  64  squares.  Total  areas  disinfected  a second  time,  | 
streets  and  premises  of  24  squares.  The  following  is  the  census  of  the  39  inhabited  squares  1 
bounded  by  Magazine  street  and  the  river  front,  St.  Andrew  and  Second  streets,  not  inelud - X 
ing  asylums.  Number  of  premises,  1143;  persons  on  premises,  white,  5869;  colored,  538;  total  } 
population,  6407 ; born  in  New  Orleans,  3713;  in  Louisiana,  211;  arrived  in  New  Orleans  since  5 
1867,  the  date  of  the  last  great  epidemic,  467  ; born  in  New  Orleans  since  1867,  1760;  number 
who  have  already  had  yellow  fever,  white,  1163;  colored,  34;  total  persons  who  had  had  yellow 
fever,  1196;  number  who  never  had  yellow  fever,  5211. 

Dr.  Holt  concludes,  from  his  experience  during  the  yellow  fever  of  1876,  in  New  Orleans: — 

“That  carbolic  acid  not  only  retards  decomposition  and  modifies  its  products,  but  seems  to  I 
destroy  directly  the  yellow  fever  infection,  and  in  order  to  accomplish  this,  it  is  not  essential  that  ? 
all  surfaces  be  subjected  to  the  actual  contact  of  the  disinfectant.  The  destructive  influence  seems  | 
to  extend  beyond  the  limit  of  actual  contact. 

“ That  when  the  suppression  of  the  disease  is  to  be  accomplished  by  disinfectants,  these  are  to  I 
be  thoroughly  applied  from  the  first  moment  of  alarm.  There  must  be  an  absolute  parallel 
between  the  management  of  this  disease  and  the  management  of  a fire.  The  Board  of  Health  is  1 
the  central  office,  each  physician  having  at  heart  the  welfare  of  his  fellow  citizens  constitutes  | 
himself,  as  it  were,  an  alarm  box.  The  first  occasion  of  alarm  is  made  known  to  the  board.  . . As 
in  the  case  of  fire,  the  only  hope  of  extinguishing  a pestilence  is  in  the  very  earliest  knowledge  of 
its  existence.”* 

YELLOW  FEVER  OF  1877. 

New  Orleans  escaped  yellow  fever  in  1877,  only  one  death  having  been  reported  from  this 
disease,  and  this  occurred  in  the  month  of  November,  in  the  case  of  a passenger  from  Havana,  who 
passed  through  the  quarantine. 

YELLOW  FEVER  OF  1878. 

Yellow  fever  appeared  in  the  month  of  May,  but  did  not  commence  its  ravages  until  July.  Its 
presence  was  not  seriously  suspected  or  fully  recognized  until  the  second  week  in  July. 

The  deaths  from  yellow  fever  in  Now  Orleans  in  1878  were  as  follows: — 


May 2 

Juno 0 

July 50 

August 974 

September 1873 

October 1044 

November 90 

December 3 



Total 4056 


* “ Analysis  of  the  Record  of  Yellow  Fever  in  New  Orleans  in  1876.”  New  Orleans  Med.  & Surg.  Journ., 
N.  S.  IV,  No.  4,  July,  1877,  p.  494. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  421 


Immediately  upon  the  recognition  of  the  disease,  in  tho  month  of  July,  Dr.  Samuel  Choppin, 
President  of  the  Board  of  Health  of  the  State  of  Louisiana,  who  appears  at  that  time  to  have 
been  a strong  believer  in  the  efficacy  of  carbolic  acid,  caused  all  the  localities  where  cases  were 
reported  to  be  thoroughly  treated  with  carbolic  acid.  The  gutters,  yards,  streets  or  lanes  and 
vacant  lots  were  literally  deluged  with  carbolic  acid. 

The  disease  was  unchecked  by  the  cordon  of  carbolic  acid,  and  marched  rapidly  from  district  to 
district  until  every  district  of  the  town  was  invaded,  and  the  infection  was  carried  by  steamboats 
and  railroads  far  into  the  interior  of  the  valley. 

The  charmed  spell  of  carbolic  acid  disinfection  of  gutters  and  streets  was  forever  broken. 

In  1879,  49  cases  of  yellow  fever  with  19  deaths  were  reported  in  a limited  area  of  the  Fourth 
District. 

YELLOW  FEVER  OF  1880. 

In  1SS0,*  one  death  occurred  in  the  Touro  Infirmary  in  the  month  of  July,  in  the  case  of  a 
sailor  on  the  bark  “ Excelsior,”  which  was  sent  back  to  quarantine,  and  the  disease  spread  no 
further. 

A case  reported  as  one  of  yellow  fever  occurred  in  October,  in  the  person  of  a young  man  re- 
cently arrived  from  the  country  ; he  was  said,  however,  to  be  a native  of  this  city. 

No  case  was  reported  in  1881,  f and  in  1882  J five  cases  were  reported,  which  proved  fatal, 
namely,  one  in  June,  one  in  July  and  two  in  August. 

Thorough  inspection  and  cleansing  and  disinfection  of  the  premises,  isolation  of  the  sick,  and 
the  prompt  destruction  by  fire  of  infected  clothing,  beds  and  bedding,  and  the  prompt  burial  of  the 
dead  were  the  measures  employed  successfully  for  the  arrest  of  the  yellow  fever  of  1882  by  the 
President  of  the  Board  of  Health.  Not  one  gallon  of  carbolic  acid  was  sprinkled  in  the  streets  or 
poured  into  the  gutters ; but  the  privies,  yards  and  houses  were  cleaned  and  disinfected. 

The  death  from  yellow  fever  reported  in  1883  $ occurred  late  in  the  season,  after  the  suspension 
of  quarantine,  the  patient  coming  from  V era  Cruz,  among  a body  of  Italian  emigrants. 

From  the  preceding  facts  relating  to  the  practice  of  disinfection  in  New  Orleans,  Louisiana, 
more  especially  with  reference  to  carbolic  acid  disinfection  against  yellow  fever,  smallpox  and 
cholera,  the  following  conclusions  may  be  drawn : — 

1 . In  all  efforts  to  arrest  the  spread  of  yellow  fever  by  disinfectants  and  sanitary  measures  in 
cities  situated  in  temperate  latitudes  where  yellow  fever  is  not  indigenous  it  must  be  noted  : — 

(а)  Epidemics  of  yellow  fever  vary  greatly  in  their  rate  of  increase,  and  in  the  rapidity  of  their 

spread,  and  the  size  of  the  area  which  they  may  invade. 

(б)  Even  in  a large  city  containing  a large  unacclimated  population,  and  possessing  apparently 

all  the  topographical  and  climatic  conditions  favorable  for  the  rapid  spread  of  yellow  fever, 
the  disease,  although  introduced  from  foreign  parts,  may  for  a series  of  years  show  no 
disposition  to  spread. 

(c)  The  origin  and  spread  of  yellow  fever  is  closely  related  to  the  temperature. 

These  propositions  will  be  clearly  illustrated  by  the  following  important  table,  illustrating  the 
natural  history  of  yellow  fever  in  its  relations  to  climate  and  seasons  in  New  Orleans,  Louisiana  : — 


* Report  of  Joseph  Jones,  M.D.,  President  Board  of  Health,  State  of  Louisiana,  1880. 
t Ibid.,  1881.  $ Ibid.,  1882.  ? Ibid.,  1883. 


422 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


MONTHLY  DEATHS  BY  YELLOW  FEVER  DURING  A PERIOD  OF  THIRTY- 

TWO  YEARS,  1847-1878.* 


Year. 

May. 

June. 

July. 

I 

August. 

1 

September. 

October. 

November. 

December. 

Total  Deaths  by 
Yellow  Fever. 

Date  of  First  Case. 

1847 

74 

965 

1,100 

198 

33 

2,306 

July  6th. 

1848 

4 

33 

200 

467 

226 

20 

808 

June  21st. 

1849 

1 

17 

314 

416 

112 

9 

769 

July  28th. 

1850 

i 

4 

62 

33 

4 

107 

One  death  Jan.;  two  March;  one  May. 

1851 

8 

6 

2 

1 

17 

1852 

2 

8 

91 

198 

105 

ii 

456 

July. 

1853 

2 

31 

1,521 

5,133 

982 

147 

28 

4 

7,849 

May  22d. 

1854 

2 

29 

532 

1,234 

490 

131 

7 

2,425 

First  death  June  12th. 

1855 

5 

382 

1,286 

874 

97 

19 

7 

2,670 

June  19th. 

1856 

14 

40 

16 

4 

7 

74 

June  28th. 

10  years.. 

3 

42 

2,046 

8,225 

5,041 

1,794 

453 

55 

17  481 

1857 

1 

1 

1 

8 

98 

82 

8 

200 

One  death  reported  in  January. 

1858 

2 

132 

1,140 

2,204 

1,137 

224 

5 

4,845 

One  death  reported  January  10th. 

1859 

1 

59 

28 

3 

91 

June. 

1860 

3 

7 

e 

15 

1861 

... 

1862 

1 

l 

2 

1863 

2 

2 

About  100  cases  in  U.  S.  River  Fleet. 

1864 

1865 

1 

4 

1 

1 

6 

1 

About  200  cases  and  57  deaths,  U.  S. 
Gunboats  and  River  Fleet. 

1866 

5 

56 

89 

31 

4 

192 

One  death  August  10th. 

10  years.. 

3 

137 

1,154 

2,277 

1,387 

366 

21 

. 5,354 

1867 

3 

11 

255 

1,637 

1,072 

103 

26 

3,107 

One  case  died  June  10th. 

1868 

5 

5 

October  5th,  died  in  Charity  Hospital. 

1869 

1 

2 

3 

July  17th. 

1870 

i 

3 

231 

242 

106 

5 

588 

May  26th. 

1871 

2 

9 

22 

19 

2 

54 

July  30th. 

1872 

1 

5 

24 

7 

2 

39 

August  28th. 

1873 

3 

19 

208 

79 

17 

226 

July  9th. 

1874 

... 

2 

6 

2 

2 

11 

August  19th. 

1875 

... 

5 

24 

20 

9 

3 

61 

August  8th. 

1876 

1 

19 

17 

4 

1 

42 

August  11th. 

10  years.. 

4 

15 

286 

2,135 

1,489 

267 

40 

4,136 

1877 

1 

1 

November. 

1878 

2 

50 

974 

1,893 

1044 

90 

3 

4,056 

May  25th. 

2 years.... 

2- 

50 

974 

1,893 

1.044 

91 

3 

4,057 

32  years.. 

5 

49 

2,248 

10,639 

11,346 

5,714 

1,177 

119 

31,028 

1879 

19 

1880 

1 

1 

2 

1881 

0 

1882 

1 

1 

2 

4 

1883 

1 

1 

Total 

5 

50 

2,250 

10,641 

11,346 

5,715 

1,178 

119 

31,054 

* Reports  of  Joseph  Jones,  M.  D.,  President  of  the  Board  of  Health,  State  of  Louisiana,  18S0,  1 SSI, 
1882,  1883. 


2.  From  the  preceding  table  it  is  evident  that,  as  a general  rule,  the  great  epidemics,  ns  those 
of  1847,  1849,  1853,  1854,  1855,  1858,  1867  and  1878,  commenced  early  in  tho  hot  months  (May, 
June  and  July),  and  attained  their  maximum  intensity  in  August  and  September.  Thus,  during 
the  period  of  thirty-two  years  tho  deaths  from  yellow  fever  in  New  Orleans  were  as  follows: 

January,  6;  February,  0;  March,  2;  April,  0;  May,  5 ; June,  49;  July,  2248;  Augu.t, 
10,639;  September,  11,346;  October,  5714;  November,  1177;  December,  119. 

■ Tho  curve  of  yellow  fever,  therefore,  corresponds,  to  a certain  extent,  with  the  curve  of  tern 
perature.  Thus,  from  the  records  of  thirty-eight  years,  which  I have  consolidated  and  calculated 
from  the  most  reliable  data,  the  moan  temperature  of  New  Orleans  is  as  follows:  January,  50.-8. 
February,  58.03;  March,  64.27;  April,  69.41;  May,  75.90;  June,  81.35;  July,  83.21;  August, 
83.14;  September,  79.64;  October,  70.27;  November,  62.80;  December,  56.43;  spring.  69. oo: 
summer,  82.53;  autumn,  70.75;  winter,  56.91;  year,  69.51.  The  origin  and  spread  of 
fever,  therefore,  depends  absolutely  upon  an  elevated  temperature,  ranging  from  70°  to  85  •» 


SECTION  XV — rUBLIC  AND  INTERNATIONAL  HYGIENE.  423 


and  its  decline  depends  upon  a mean  temperature,  ranging  from  65°  to  56°  F.  These  figures,  of 
course,  relate  to  the  mean  or  avorage  monthly  temperature,  the  extremes  being  much  higher  or 
lower,  ranging  during  the  year,  in  New  Orleans,  as  shown  by  meteorological  observations,  extend- 
ing from  1817  to  1878,  from  17°  F.  to  100°  F. 

3.  Carbolic  acid  disinfection,  as  practiced  in  New  Orleans — by  deluging  the  gutters  and  streets 
— has  no  value  to  arrest  the  spread  of  yellow  fever,  smallpox  or  Asiatic  cholera. 

4.  Yellow  fever  germs  do  not  originate  in  the  foul  canals  and  filthy  gutters  of  New  Orleans, 
and  cannot  be  prevented  from  germinating  by  pouring  disinfectants  into  these  foul  receptacles. 

5.  Yellow  fever  germs  do  not  travel  along  the  surface  of  the  ground  at  a certain  rate,  and 
their  march  cannot  be  arrested  or  their  infective  power  destroyed  by  the  saturation  of  the  soil  by 
any  known  disinfectant.  The  truth  of  this  proposition  has  been  established,  as  far  as  carbolic 
acid  is  concerned,  upon  a grand  scale  in  New  Orleans,  and  especially  by  the  results  of  the  great 
yellow-fever  epidemic  of  1878. 

6.  Yellow  fever  is  not  indigenous  to  New  Orleans. 

7.  Yellow  fever  is  not  indigenous  to  Louisiana. 

8.  Yellow  fever  is  not  indigenous  to  the  Mississippi  valley. 

9.  Yellow  fever  can  be  excluded  from  New  Orleans  and  the  Mississippi  valley  by  a rigid  and 
effective  quarantine. 

10.  Quarantine,  to  be  effective,  must  include  not  merely  inspection  and  detention  for  a reason- 
able period,  but  also  discharge  of  infected  cargo,  ballast,  clothing,  baggage  and  bedding,  thorough 
ventilation,  fumigation,  disinfection  and  cleansing. 

11.  All  ports  in  which  yellow  fever  may  be  introduced  should  be  kept  under  thorough  and 
daily  inspection,  said  inspection  to  extend  to  the  shipping  as  well  as  to  the  dwellings  and 
inhabitants. 

12.  In  the  event  of  the  appearance  of  yellow  fever,  the  case  or  cases  should  be  at  once  isolated 
and  the  surrounding  houses,  yards  and  streets  thoroughly  cleansed  and  disinfected.  Fight  the 
enemy  immediately,  on  sight,  vigorously,  continuously,  and  with  the  best-known  agents  and 
appliances. 


After  the  reading  of  the  address  of  the  President  and  the  appendix  thereto,  Dr. 
George  Troup  Maxwell  remarked  that  the  reading  of  these  papers  would  alone, 
in  the  broad  view  which  they  unfolded  of  the  science  of  public  and  international 
hygiene,  and  in  the  vast  number  of  facts  which  they  contained  illustrating  the  history 
of  naval  hygiene,  and  of  disinfectants  and  disinfection,  amply  repay  him  for  his  long 
and  fatiguing  journey  from  Ocala,  Florida. 

Dr.  W.  L.  Schenck,  of  Osage  City,  Kansas,  after  dealing  with  the  importance 
of  publishing  the  address  and  the  appendix  without  alteration  or  abridgment, 
offered  the  following  resolution: — 

Resolved , That  the  thanks  of  the  Section  be  voted  to  the  President  for  his  able 
address. 

The  French  Secretary,  Dr.  Le  Monnier,  said  that  the  author  of  these  papers 
had  devoted  his  life  to  the  investigation  of  malarial  and  yellow  fever  in  various 
Southern  cities,  but  more  especially  in  Savannah,  Georgia,  and  New  Orleans, 
Louisiana. 

Dr.  Le  Monnier  further  stated  that  the  position  of  Secretary  of  the  Board  of 
Health  of  the  State  of  Louisiana  and  Coroner  of  the  Parish  of  Orleans,  which 
he  himself  had  filled,  as  well  as  his  private  practice,  during  the  past  twenty  years 
(the  period  embraced  in  the  history  of  disinfection,  and  especially  of  carbolic  acid 


424 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


disinfection,  in  New  Orleans,  here  unfolded),  enabled  him  to  affirm  positively  that  in 
no  other  paper  or  work  could  such  accurate  and  extensive  information  be  obtained. 

The  following  resolution  was  offered  by  Dr.  R.  Le  Monnier,  of  New  Orleans, 
seconded  by  J.  B.  Lindsley,  of  Nashville,  Tenn.,  and  adopted,  viz.: — 

Whereas,  The  Address,  with  its  Appendix,  of  our  President,  is  replete  with  the 
most  minute  details  of  the  history  of  that  terrible  scourge,  Yellow  Fever,  a subject 
of  the  highest  interest  to  the  whole  Mississippi  Valley,  and  perforce  to  the  people 
of  the  United  States,  be  it  therefore 

Resolved , That  it  is  the  unanimous  wish  of  this  Section  that  the  Publishing 
Committee  be  requested  to  publish  in  full  both  the  Address  and  Appendix. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  425 


SECOND  DAY. 


REPORT  OF  AN  INQUIRY  INTO  THE  FACTS  RELATING  TO  THE 
EFFECTS  OF  OVERFLOWS  OF  THE  MISSISSIPPI  RIVER  AND 
ITS  TRIBUTARIES,  AND  RICE  CULTURE.  UPON  THE  PUBLIC 
HEALTH,  AND  THE  BEST  MEANS  OF  CONTROLLING  THEIR 
BALEFUL  INFLUENCE. 

RAPPORT  D’UNE  ENQUETE  SUR  LES  EFFETS  DES  DEBORDEMENTS  DU  MISSIS- 
SIPPI ET  DE  SES  TRIBUTAIRES,  ET  DE  LA  CULTURE  DU  RIZ,  RELATIVEMENT 
A LA  SANTE  PUBLIQUE,  ET  LES  MEILLEURS  MOYENS  DE  CONTROLER  LEUR 
PERNICIEUSE  INFLUENCE. 



BERICHT  UBER  EINE  UNTERSUCHUNG  DER  THATSACHEN,  WELCHE  SICH  AUF  DIE  WIR- 
KUNGEN  DER  UBERSCHIVEMMUNGEN  DES  MISSISSIPPI  UND  SEINER  NEBENFLUSSE,  UND 
DES  REISSBAUES  AUF  DIE  OFFENTLICHE  GESUNDHEIT  BEZIEHEN,  UND  DIE  RESTEN 
MITTEL  ZUR  BEHERRSCHUNG  IHRES  VERDERBLICHEN  EINFLUSSES. 

BY  RICHARD  H.  DAY,  M.  D. , 

Baton  Rouge,  La. 

Being  appointed  by  the  distinguished  and  worthy  President  of  the  Fifteenth  Section 
of  the  Ninth  International  Medical  Congress  to  investigate  the  effects  of  overflows 
(chiefly)  of  the  Mississippi  river,  and  rice  culture,  upon  the  public  health,  I beg  to 
state  that  I have  diligently  labored  to  discharge  the  duties  involved  in  this  investigation. 

Realizing  the  high  and  paramount  importance  of  the  strictest  exactitude  in  all  med- 

!ical  researches,  I endeavored  to  make  my  inquiries  comprehensive  and  searching,  that 
I might  obtain  such  data  and  facts  as  would  be  reliable  and  prove  of  real  value  to  the 
medical  profession.  To  this  end,  in  consultation  with  the  President  of  the  Fifteenth 
Section,  and  at  his  suggestion,  I drew  up  the  annexed  series  of  questions  to  the  medical 
profession,  which  were  kindly  published,  first  in  the  Journal  of  the  American  Medical 
Association , and  subsequently  in  Gaillard’s  Medical  Journal  and  in  Daniel’s  Texas  Med- 
ical Journal , for  which  courtesy  and  kindness  I now  tender  publicly  my  sincere  and 
hearty  thanks.  The  more  fully  to  reach  the  profession  and  enlist  their  earnest  coopera- 
tion, and  to  obtain  the  results  of  their  observations  and  rich  experiences,  I had  five 
hundred  copies  of  the  questions  printed  in  letter  form,  and  mailed  a copy  to  every 
physician  of  prominence  in  every  Southern  State  whose  address  I could  learn,  and 
whose  locality  I had  reason  to  helieve  embraced  such  local  conditions  as  to  give  him 
the  ability  to  answer  the  questions  with  precision  and  clearness.  Besides  this,  I wrote 
many  private  letters,  urging  upon  each  to  whom  I wrote  the  high  importance  of  his 
personal  effort  to  give  all  the  facts,  within  the  range  of  his  own  personal  knowledge, 
elucidating  the  questions  propounded. 

I was  not  ignorant  of  the  fact  that,  from  the  earliest  history  of  medicine  down  to 
the  present  day,  marshy  and  low-lying  sections  of  lauds  subject  to  inundations,  in  the 
tropic,  semi-tropic  and  even  temperate  zones,  had  always  been  regarded,  both  by  the 
1 profession  and  the  laity,  as  fruitful  fields  of  bilious  fevers,  dysenteries  and  allied  dis- 


426 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


eases  when  these  soils,  as  the  waters  subsided,  were  exposed  to  an  elevated  temperature 
and  the  scorching  rays  of  the  sun.  But  it  was  to  get  the  facts  gained  hy  the  observa- 
tions and  experiences  of  Southern  physicians,  relating  to  overflows  and  rice  culture,  that 
this  investigation  was  initiated,  and  to  arrive  at  true  conclusions  in  relation  to  the 
potential  factors  and  conditions  affecting  or  modifying  these  general  results.  This  was 
deemed  essential,  since  it  was  well  known  that  every  overflow  of  the  Mississippi  river 
and  its  tributaries  was  not  succeeded  by  general  sickness  of  the  immediate  inhab- 
itants, nor,  to  the  same  extent  in  every  portion  of  the  inundated  districts,  and  that 
rice  culture,  was  not  always  attended  with  the  same  injurious  effects  upon  the  health 
of  the  people  in  these  sections. 

It  is  to  be  regretted,  indeed,  that  our  busy  and  intelligent  Southern  medical  prac- 
titioners have  been  so  remiss  in  keeping  records  of  dates  and  facts  touching  these  sub- 
jects, and  that,  in  consequence,  so  few  have  been  able  to  reply  to  the  questions  asked, 
corresponding  to  the  standard  of  our  present  enlightened  demands.  It  is  not  to  be  in- 
ferred from  this,  however,  that  this  class  of  physicians  are  lacking  in  general  intelligence, 
mental  acumen,  or  interest  in  the  advancement  of  their  profession.  So  far  from  this, 
they  will  be  found  in  consultation  clear  and  independent  thinkers,  and  ready  and  skill- 
ful practitioners  of  medicine;  they  simply  have  not  aspired  to  authorship  and  notoriety, 
and  have  been  content  to  utilize  the  fruits  of  their  rich  experiences  for  the  benefit  of  their 
own  immediate  neighbors  and  patrons.  I deem  this  expression  of  truth  but  a simple 
act  of  justice  to  the  great  body  of  physicians  outside  of  our  large  cities  and  the  great 
centres  of  medical  thought,  activity  and  scientific  research.  And  to  the  more  promi- 
nent of  this  class  I have  mainly  addressed  my  inquiries. 

I have  received  replies  from  physicians  of  Louisiana,  Mississippi,  Alabama,  North 
and  South  Carolina  and  Georgia.  Three  write  that,  not  living  in  localities  subject  to 
overflow,  nor  Avhere  rice  is  cultivated,  they  have  no  experience  in  the  matter,  and 
hence  no  facts  or  data  to  give. 

All  the  physicians  living  in  districts  subject  to  overflow,  without  a single  dissen- 
tient, affirm  that  there  is  an  increase  of  sickness  immediately  succeeding  overflows. 
That  this  sickness  is  malarial  in  character,  intermittent,  remittent,  algid  and  pernicious 
in  type,  and  is  lessened  or  modified  in  character  by  local  conditions  ; such  as  a soil 
naturally  or  artificially  well-drained  ; the  period  of  overflow,  whether  early  or  late  in 
the  season,  and  of  short  or  long  duration,  and  by  the  occurrence  of  copious. showers  of 
rain  during  the  recession  of  the  waters,  thereby  flushing  the  soil  and  washing  the  vege- 
table and  animal  matters  off,  deposited  by  the  inundating  waters. 

I quote  as  follows  : Dr.  I.  P.  Moore,  an  educated  and  skillful  physician  of  Yazoo 
City,  Miss.,  says:  “I  have  kept  the  dates  of  those  overflows  which  were  unusual, 

1867,  1882,  1883,  1884 — partial  in  1874.  In  almost  any  year  much  of  the  low  lands  are 
covered  with  water.  Health  is  very  much  influenced  in  overflows,  or  even  in  high 
water  years,  by  the  earliness  or  lateness  of  the  season  in  which  the  waters  recede  within 
their  banks.  The  later  receding,  the  more  sickness;  but  even  when  late,  should  we  have 
hard  showers  of  rain  to  wash  the  banks  and  flush  the  ground  occasionally  as  the  water 
leaves,  the  health  is  greatly  promoted.  Sickness  is  at  once  checked  by  a copious  rain.” 

Dr.  A.  Maguire,  of  Jeaneratte,  La.,  and  long  a resident  of  St.  Mary  Parish,  a 
highly  educated  and  able  physician,  writes:  “In  1879,  there  was  a severe  storm  in 
September.  The  water  remained  some  forty-eight  hours  submerging  vegetables.  From 
the  fields,  fetid  exhalations  from  decayed  pea  vines,  etc.,  poisoned  the  atmosphere,  and 
in  the  country  on  the  Franklin  road  from  P.  L.  to  G.  D’s,  many  cases  of  pernicious 
hemorrhagic  fever  took  place.” 

Dr.  C.  J.  Ducot6,  of  Avoyelles  Parish,  a very  successful  and  educated  physician, 
says,  “I  have  generally  observed  an  increase  of  sickness  immediately  succeeding  these 
overflows — intermittent  and  remittent  malarial  fevers  and  malarial  hcematuria,” 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  427 


Dr.  C.  D.  Owens,  of  the  same  Parish,  one  of  our  most  cultivated  physicians,  testi- 
fies: “ I have  invariably  observed  an  increaseof  sickness  succeeding  every  overflow  of 
which  I have  had  any  knowledge,  of  all  forms  of  recognized  malarial  fever,  including 
dysentery ; the  diseases  assuming  adynamic  or  ataxic  features  well  pronounced ; local 
dropsies,  jaundice  and  hemorrhages  being  often  the  attendants  or  sequel®  of  many  of 
these  cases.” 

Dr.  L’Admirault  of  Point  Coupe  Parish,  of  long  experience  and  one  of  our  best 
educated  physicians,  states  : “ During  the  inundation,  diarrhoeas  and  dysentery;  after 
recessiou,  malarial  fevers  of  all  types,  pernicious,  comatose  (convulsive  among  children), 
some  algid  and  choleraic  in  form.” 

Dr.  L.  F.  Donaldson,  of  Bonne  Carre,  La.,  a very  intelligent  and  skillful  practi- 
tioner of  medicine,  writes:  “ During  the  overflow  not  much  change,  if  any,  for  the 
better;  but  as  soon  as  the  waters  recede,  then  malarial  complaints,  dysentery  and  diar- 
rhoeas are  very  rife.  Malarial  fevers  and  dysentery  almost  epidemic  and  very  fatal  in 
character.”  And  such  is  the  testimony  of  all  as  to  the  effects  of  overflows  upon  the 
public  health. 

RICE  CULTURE. 

It  is  pretty  clearly  established  by  the  experience  of  these  careful  observers,  that  the 
cultivation  of  rice  is  not,  per  se,  and  necessarily,  so  detrimental  to  health  as  is  generally 
supposed,  and  is  not  conducive  to  the  production  of  malarial  hannaturia;  but  that  its 
obnoxiousness  to  health  is  the  result  of  the  improper  and  insanitary  mode  of  its  culti- 
vation. Dr.  O.  Huard,  formerly  of  New  Orleans,  but  for  the  last  ten  years  a resideut 
practitioner  of  St.  John  Parish,  and,  withal,  a very  intelligent  and  close  medical  obser- 
ver, writes:  “Rice  is  very  extensively  cultivated  in  this  parish,  and  yet,  with  an 

extensive  practice,  I have  only  seen  three  cases  of  malarial  luematuria  in  these  ten 
years.  And  I attribute  this  to  the  fact  that  the  lands  slope  from  the  river  back,  with 

igood  natural  drainage,  so  that  as  soon  as  the  water  is  let  off  the  rice,  the  lands  quickly 
dry;  while  in  St.  James  Parish,  about  Grand  Point,  where  no  rice  is  cultivated,  but 
largely  tobacco,  malarial  luematuria  rages  furiously  every  summer.” 

It  is  the  general  experience  that  malarial  luematuria  has  increased  in  frequency, 
if  not  in  severity,  during  the  past  forty  years,  but  that  said  increase  is  not  due  to  the 
increased  cultivation  of  rice.  Dr.  C.  J.  Ducote,  already  quoted,  writes:  “Malarial 
luematuria  has  increased  in  frequency,  if  not  in  severity,  during  the  last  forty  years; 
that  said  increase  is  not  due,  at  least  in  Avoyelles  Parish,  to  the  increased  cultivation 
of  rice,  for  there  is  a larger  number  of  cases  of  that  malady  in  the  low  lands  where  no 
rice  is  cultivated,  than  there  is  on  the  high  lands  where  it  is  cultivated.” 

Dr.  I.  B.  Moore,  of  Yazoo  City,  Miss.,  says:  “ Hsematuria  (malarial),  so  far  as  I 
know,  was  unknown  here  till  1868,  when  it  developed  in  quite  a number  of  cases  in 
the  persons  of  those  who  had  suffered  frequent  attacks  of  fever  in  1867,  continuing 
through  the  winter  and  spring  of  1868,  producing  its  usual  morbid  change,  malarial 
cachexia,  great  poverty  of  blood,  sallow  skin,  jaundiced  conjunctive,  enlarged  spleen, 
urine  loaded  with  bile,  etc.  This  was  the  class  of  cases,  with  but  few  exceptions, 
attacked  with  malarial  hematuria;  and  ever  since,  such  has  been  the  case.  About  as 
many  cases  in  1868  as  any  year  since,  showing  but  little  or  no  increase  since  that 
date.” 

The  observations  and  experience  of  Dr.  Jas.  R.  Sparkman,  of  South  Carolina,  cover 
so  many  points  of  the  deepest  interest  aud  extend  over  such  a long  period  of  time,  and 
are  so  admirably  and  forcibly  expressed,  that  I am  constrained  to  incorporate  his  report 
without  abridgment. 


428 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


DR.  JAIMES  R.  SPARKMAN’S  REPORT  AND  REPLIES  TO  QUESTIONS  SUBMITTED  BY  DR. 

RICHARD  H.  DAY,  OF  BATON  ROUGE,  LA. 

“1.  I have  been  familiar  with  the  diseases  of  this  section  of  the  country  since  1836. 
My  professional  observation  covering  an  area  of  forty  miles. 

“2.  I have  had  frequent  opportunities  of  noting  the  effects  of  freshets  and  the  over- 
flows of  our  rivers  upon  the  public  health  of  this  locality. 

“3.  An  increase  of  sickness  generally  follows  immediately  after  the  subsidence  of 
these  overflows. 

“4.  Occurring  as  they  do,  at  all  seasons,  we  have  noted  during  and  after  a winter  or 
spring  freshet  an  increase  of  catarrhal  fever  with  bronchial  and  pneumonic  trouble. 
Occurring  in  summer  or  autumn,  congestive  fever  follows,  sometimes  of  malignant  type. 
The  general  rule  is  an  increase  of  malarial  fever,  both  remittent  and  intermittent;  for- 
merly, the  mortality  was  grave,  but  since  the  use  and  dosage  of  quinine  has  become 
better  understood,  malarial  fevers  are  successfully  treated  and  excite  but  little  appre- 
hension. 

“5.  No  statistics  now  available;  all  my  memoranda  of  endemics  and  epidemics  from 
1836  to  1861  lost  in  the  vital  struggle  through  which  we  passed  from  1861  to  1865. 

‘ 1 6.  The  effects  of  rice  culture  upon  the  public  health  can  only  be  answered  satisfac- 
torily by  collection  of  facts  (from  memory)  during  my  experience  of  half  a century. 
You  can  make  such  a digest  of  this  collection  as  will  suit  your  purposes  for  publica- 
tion. 

“ I shall  have  to  consider  topography  in  connection  with  different  systems  of  culture. 
In  this  country  there  are  upward  of  fifty  thousand  acres  of  wood  and  marsh  lands 
subject  to  the  influence  of  the  sea  tides,  with  a rise  and  fall  of  three  to  five  feet,  less  as 
you  advance  up  the  rivers.  Of  these  tide  lands,  the  area  of  cultivation  up  to  1860  was 
about  forty-six  thousand  acres.  Rice  the  specialty,  since  its  introduction  as  a crop  in 
the  last  century;  the  preparation  for  cultivation  involves  an  elaborate  system  of  embank- 
ments with  dikes,  ditches  and  floodgates,  all  of  which  have  to  be  kept  up  annually,  for 
sufficient  drainage  to  insure  successful  cropping;  ordinary  hoe  work  and  ploughing  with 
animals  essential.  These  embankments  are  sufficient  to  resist  the  ordinary  rise  of  the 
tides,  but  during  storm  or  gale  tides  and  freshets  they  are  entirely  submerged.  The 
soil  is  entirely  alluvial,  and  these  overflows,  during  storm  or  gale  lasting  from  two  to 
four  days,  and  during  freshets  from  ten  to  thirty  days,  cause  frettings  or  washes,  or 
breaks,  not  infrequently  involving  partial  or  total  loss  of  the  crops,  with  an  unsanitary 
condition  afterward  which  bears  directly  upon  the  public  health. 

“ In  ante-bellum  days  my  professional  experience  covered  some  thirty  odd  rice  estates, 
with  a slave  population  of  about  four  thousand  and  white  several  hundred.  Most  of 
the  managers  of  these  estates,  with  their  families,  resided  the  entire  year  directly  on 
the  plantations.  The  owner,  or  proprietor,  spent  the  summer  months  in  travel,  or 
resorted  to  the  seashore  or  adjacent  islands,  or  select  pine-land  villages,  a few  miles 
distant  from  the  rice  fields.  For  many  decades  prior  to  1840  Georgetown  was  regarded 
as  one  of  the  most  sickly  ports  of  the  Atlantic  sea  coast.  The  most  fatal  fever  was 
called  “cold  fever,”  and  was  the  dread  of  all  strangers,  especially  the  seafaring  class 
who  visited  this  port  during  the  sickly  season.  No  vital  statistics  were  then  kept,  and 
the  mortality  cannot  be  reached;  but  this  congestive  type  of  fever  was  unmistakably 
pernicious  and  fatal.  In  a conversation  with  the  quarantine  physician  at  Staten 
Island,  New  York,  he  informed  me  that  the  fever  of  Georgetown  had  resisted  their 
best  efforts  to  control  it,  and  that  nearly  every  man  put  ashore  there  for  treatment 
died  promptly.  I understand  a better  record  is  now  reported  there. 

“ The  system  of  rice  culture  prior  to  1840  I conceive  to  have  been  the  chief  factor  in 
the  development  of  the  malignant  fever  which  had  for  half  a century  before  decimated 
the  population  of  the  town,  which  is  surrouuded  by  rice  fields.  For  the  steady  and 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  429 


uniform  maturity  of  the  grain  it  was  considered  essential  that  the  rice  plant  should 
receive  uniform  supply  of  nutriment.  To  this  end,  the  long  or  “lay-by  flow”  was 
put  on  the  fields  as  soon  as  the  conception  of  the  grain  was  determined,  and  this  flow 
was  kept  steady,  at  one  gauge,  until  the  grain  was  ripe,  or  ready  for  the  harvest.  The 
water  was  never  drawn  off,  with  a view  to  freshening  it,  hut  this  “lay-by”  or  long 
flow  was  continued  from  forty -five  to  sixty  days,  until  the  day  of  the  harvest.  The  result 
may  readily  be  conceived.  The  decomposition  and  putrescence  of  forty-six  thousand 
acres  of  flowed  land,  exposed  to  summer  and  autumnal  sun  heat  in  this  climate,  was 
quite  sufficient,  we  think,  to  generate  the  most  deadly  miasm.  A case  in  point  demon- 
strating the  poisonous  character  of  the  effluvia  resulting,  was  that  of  a wealthy  planter 
(afterward  governor  of  the  State),  who  stood  at  the  floodgate  of  a large  field  while  the 
water  was  draining  off,  preparatory  to  the  harvest.  The  stench  was  intolerable;  he 
sickened,  nauseated  and  was  obliged  to  leave.  On  his  way  home — a distance  of  six 
miles — a protracted  chill  overtoook  him;  a congestive  fever  followed,  which  nearly  cost 
him  his  life.  An  exposure  of  two  hours  at  the  floodgates  was  followed,  in  less  than  six 
hours,  with  malarial  fever  of  nine  days.  From  summer  freshets  similar  results  fol- 
lowed. The  summers  of  1840  and  1841  furnished  memorable  demonstration.  In  1840 
there  was  a long  and  high  overflow  of  our  rice  lands  during  the  months  of  July  and 

1 August.  The  stagnant  waters  of  the  rice  fields  were  washed  out,  as  it  were,  of  their 
embankments,  mingling  with  the  general  current  of  the  rivers,  passed  down  to  the 
ocean,  causing  a debouche  of  the  turbid  waters  for  several  miles  beyond  the  ordinary 
limit  of  the  water  from  up  the  streams.  The  influx  of  the  sea  tides  brought  back  a 
highly-offensive,  brackish  deposit,  which  skirted  high-water  mark  for  several  miles 
above  the  lighthouse,  which  is  situated  on  North  Island — below  Georgetown  about 
twelve  miles.  This  island  had  been  for  many  years  the  favorite  summer  resort  of 
many  planters  and  the  wealthier  families  of  the  town,  and  was  considered  safe  from 
fever.  The  village  consisted  of  twenty-odd  houses.  Before  the  freshet  had  subsided, 
I was  summoned  to  a case  of  “ cold  fever  ” within  a few  yards  of  the  lighthouse,  on  a 
sandy  plain  looking  directly  out  upon  the  ocean.  This  case  terminated  fatally  in  thirty- 
six  hours  from  its  first  symptoms,  and  gave  my  first  experience  with  “cold  fever.” 
My  residence  was  in  Plantersville,  a pine-land  village,  seventeen  miles  beyond  George- 
town; but  being  called  to  this  case  (one  of  my  winter  patients),  I was  reluctantly 
compelled  to  remain  on  the  island  for  ten  days,  ministering  to  others,  who  were  unable 
to  procure  medical  advice  from  Georgetown— all  the  doctors  there  being  down  with 
fever.  I attended  seventeen  cases  of  fever,  most  of  them  severe  remitting,  of  conges- 
tive type— all  traced  directly  to  the  poisoning  influence  of  this  August  freshet. 

“ In  1841  a similar  invasion  of  fever  occurred  after  a slight  freshet  in  August — 
nearly  every  house  on  the  island  having  sickness,  which  caused  the  abandonment  of 
the  island  as  a summer  retreat,  from  that  year.  At  the  beginning  of  that  decade  I 
strenuously  urged  the  change  of  rice  culture,  on  the  score  of  public  health.  Irrigation 
of  the  rice  fields  was  adopted  generally — say  twice  or  thrice  a week — in  lieu  of  the 
long  stagnant  “ lay-by  flow,”  and  preparatory  to  the  harvest  the  new  plan  was  adopted 
of  washing  out  the  fields  by  the  free  ingress  and  egress  of  the  waters  several  days 
before  the  harvest  commenced.  This  at  once  insured  a better  condition  of  things  for 
ourselves  and  farm  hands,  and  beyond  question,  I say  that  the  public  health  has  im- 
proved. In  fact,  the  town  of  Georgetown  to-day  will  show  as  good  a statistical  record 
as  most  of  our  Southern  cities. 

“ Many  intelligent  observers  formerly  claimed  that  the  negro  was  not  subject  to  cli- 
mate fever — from  the  experience  derived  from  the  imported  African  and  his  immediate 
descendants — at  the  beginning  of  this  century.  At  this  date  it  is  conceded  that  a 
certain  degree  of  acclimation  can  be  secured  by  continuous  residence  immediately  on 
the  rivers,  and  also  that  the  colored  man  is  not  as  liable  to  malarial  troubles  as  the 


430 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


white.  But  my  experience  is,  that  neither  white  nor  black  is  exempt,  children  of  both 
classes  being  more  liable  than  adults. 

“ As  to  drinking  water,  while  the  rivers  are  ordinarily  regarded  as  wholesome,  the 
custom  is  to  supply  our  field  laborers  with  water  from  our  welLs  and  springs — conveyed 
in  barrels  and  jugs — during  the  season  of  planting  and  hoeing.  Ditch  or  dike  water 
is,  and  should  be,  forbidden  at  all  seasons. 

“ I have  no  experience  with  convicts  or  State  prisoners  on  rice  estates.  No  cisterns, 
except  in  the  town  of  Georgetown,  and  but  few  there;  well  water  the  main  reliance  of 
the  whole  county.  ’ ’ 

The  foregoing  reports  reveal  a remarkable  unanimity  of  medical  experience,  col- 
lected, as  it  is,  from  physicians  residing  in  separate  and  remote  sections  of  our  country, 
each  reporting  facts  observed  by  himself,  without  conference  or  consultation  with  the 
others,  and  is  so  much  the  more  reliable  and  valuable  to  the  profession  as  a working 
basis  in  practical  sanitation. 

MALARIAL  SUSCEPTIBILITY  OF  THE  AFRICAN. 

Whether  the  negro  is  equally  susceptible  with  the  white  race  to  the  noxious  influ- 
ences of  overflows,  is  a question  somewhat  mooted.  The  general  impression  prevails 
that  he  is  not.  I again  quote  : — 

Dr.  Ducote. — “ The  white  is  more  susceptible  to  the  effects  of  overflows  and  rice 
culture  than  the  colored  race.  ’ ’ 

Dr.  A.  Maguire. — “ More  severe  on  whites  than  blacks.” 

Dr.  C.  D.  Owens. — “Colored  race  resists  the  effects-of  all  malarial  causes  more  than 
do  the  whites,  but  as  the  former  are  leas  careful  in  regard  to  regimen  and  the  laws  of 
health,  they  sicken  in  about  the  same  proportion.  It  is,  therefore,  difficult  to  separate 
the  effects  of  overflows,  as  regards  the  colored  race,  from  want  of  sanitation,  which 
must  be  credited  with  some  part  of  the  cause  of  sickness  among  them.” 

Dr.  McKinnon.— “ Cotton  plantations  on  the  Alabama  river  are  almost  depopulated 
of  white  people  from  malarial  causes,  increased,  no  doubt,  from  overflows.  Colored 
people  seem  to  enjoy  an  immunity  against  these  ills  to  a very  great  extent.” 

Dr.  Donaldson. — “I  notice  a difference  between  the  two  races.” 

Dr.  C.  P.  Moore. — “Colored  are  less  affected  than  whites  by  malaria,  and  hence 
less  affected  by  overflows.  ’ ’ 

Dr.  Sparkman. — “ Many  intelligent  observers  formerly  claimed  that  the  negro  was 
not  subject  to  climate  fever,  from  the  experience  derived  from  the  imported  African  and 
his  immediate  descendants  at  the  beginning  of  this  century.  At  this  date  it  is  con- 
ceded that  a certain  degree  of  acclimation  can  be  secured  by  continuous  residence 
immediately  on  the  rivers;  and  also  that  the  colored  man  is  not  so  liable  to  malarial 
fevers  as  the  white.  But  my  experience  is,  that  neither  whites  nor  blacks  are  exempt; 
children  of  both  classes  being  more  liable  than  adults.” 

My  own  experience,  extending  over  a period  of  more  than  fifty  years,  is  that  in  all 
overflowed  and  malarious  districts  the  colored  people  are  equally  [affected  with  the 
white  people,  and  quite  as  subject  to  all  forms  of  malarial  fever,  with  a much  larger 
mortality  in  proportion  to  the  number  of  cases.  And  yet  I am  well  satisfied  that  this 
result  is  largely  due  to  the  indiscretions,  imprudences  and  negligencies  in  their  mode 
of  living  and  to  their  local  and  home  insanitary  surroundings. 

DRINKING  WATER. 

All  of  my  correspondents  fully  realize  the  injurious  effects  of  the  use  of  impure 
drinking  water,  and  the  necessity  of  an  abundant  supply  of  that  which  is  pure.  All 
give  the  first  preference  to  good  cistern  water.  In  the  light  of  recent  investigations  and 
the  positive  knowledge  thereby  gaiued  of  the  general  impurity  of  most  of  the  water 


• 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  431 


used  for  drinking  purposes,  and  its  well  known  evil  effects  upon  health,  the  question  of 
securing  pure  drinking  water  is  a problem  at  this  day  deeply  agitating  all  populous 
communities,  and  is  equally  important  to  our  rural  populations. 

Summing  up  all  the  facts  and  information  collected  in  the  foregoing  investigation, 
we  may  fairly  and  logically  formulate  the  following  propositions  : — 

1.  That  overflows,  as  a general  rule,  are  injurious  to  the  public  health. 

2.  That  they  are  more  or  less  inj  urious,  according  as  the  inundations  are  late  or 
early  in  the  season,  and  whether  of  long  or  short  duration. 

3.  That  their  evil  effects  upon  health  are  lessened,  or  entirely  antagonized,  by  good 
natural  or  artificial  drainage,  and  by  copious  showers  of  rain  occurring  during  the 
period  of  the  subsidence  of  the  waters. 

4.  That  rice  culture  is  inimical  to  health  only  by  reason  of  the  improper  and 
insanitary  manner  of  its  cultivation. 

5.  That,  as  a rule,  it  is  perhaps  true  that  the  colored  race  is  less  susceptible  to  the 
injurious  effects  of  overflows,  marshy  and  malarial  soils,  than  the  white  race. 

6.  That  carefully  caught  and  protected  rain-water  in  large  cisterns,  is  the  most 
wholesome  drinking  water,  and  should  he  used  either  for  drinking  or  cooking  purposes, 
preferably  to  all  other  waters. 

As  practical  working  corollaries,  logically  deducible  from  the  foregoing  propositions, 
to  guide  medical  men  and  sanitarians  in  their  labors  and  teachings  in  the  promotion  of 
sanitation  and  the  betterment  of  the  health  and  physical  condition  of  the  communities  in 

1 which  they  live,  the  following  rules  may  be  insisted  upon  as  necessary  and  essential : — 

1.  That  all  swampy  and  wet  soils,  and  lands  subject  to  overflows,  before  being 
settled  upon  and  put  in  cultivation,  should  he  cleared  of  trees,  underbrush,  etc.,  to 
admit  freely  the  sun’s  rays  and  the  free  circulation  of  the  winds,  and  thorough  and 
perfect  drainage  of  the  soil,  so  that  rapid  drainage  and  drying  of  the  soil  shall  not  be 
impeded. 

2.  That  in  the  cultnre  of  rice,  the  common  plan  of  keeping  the  fields  covered  for 
long  intervals  with  stagnant  water  should  be  avoided,  and  in  lieu  thereof,  frequent 
irrigation  with  fresher  and  purer  water  should  be  adopted,  and  supplied  to  the  growing 
crop  as  often  as  needed  ; and  the  ditches  and  conduits  be  so  constructed  as  to  let  off  the 
superincumbent  water  rapidly  and  promptly. 

3.  That  more  fully  to  protect  and  promote  the  health  of  the  laborers  and  residents 
in  the  river  deltas  and  the  low  lands  that  are  cultivated,  the  dwellings  should  be  not 
less  than  four  feet  from  the  ground,  the  floors  laid  tight,  and  the  doors  and  windows  so 
arranged  as  to  afford  free  ventilation,  with  galleries  on  all  sides,  wide  enough  to  prevent 
i beating  rains  from  wetting  the  rooms  and  dampening  the  beds  and  clothing. 

4.  That  the  houses  should  be  erected  upon  ridges  or  the  most  elevated  grounds,  so 
that  water  shall  not  settle  under  or  around  them  ; and  only  a few  shade  trees  be  allowed 
to  grow,  to  break  the  force  of  the  direct  rays  of  the  sun;  and  brush  and  undergrowth 
be  removed  so  as  to  facilitate  the  free  moving  of  currents  of  the  atmosphere. 

5.  The  enforcement  of  rigid  cleanliness  in  person  and  surroundings,  a due  supply 
; of  good,  wholesome  and  substantial  food,  good  cistern  water,  and  the  avoidance  of  all 
i excesses  and  intemperances  by  which  the  physical  and  mental  forces  are  weakened 
) and  broken  down,  and  resistance  to  morbid  influences  enfeebled. 

A due  observance  of  these  plain  and  common  sense  rules,  we  humbly  conceive,  will 
£ conserve  and  promote  the  health  and  comfort,  and  consequently  the  happiness  of  the 
£ people  residing  in  the  rich  and  alluvial  sections  of  this  and  other  countries.  In  the 
i language  of  Dr.  Moore,  I repeat,  ‘ 1 There  is  no  reason  why  our  rich  valley  should  not 
be  a teeming  beehive  of  industry,  filled  with  a prosperous  and  rich  people.” 

In  conclusion,  I desire  to  emphasize  the  statement,  that  whatever  facts  and  princi- 
ples have  been  educed  in  this  investigation,  reasonably  believed  to  be  promotive  of  the 


i 


432 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


health  and  comfort  of  the  inhabitants  of  the  great  Mississippi  Valley  in  these  United 
States,  are  equally  true  and  applicable  to  the  river  deltas  and  valleys  of  all  other  coun- 
tries ; and  from  this  standpoint,  as  medical  sanitarians,  we  can  take  a broad  and  com- 
prehensive view  of  the  field  of  practical  sanitation,  and  anticipate  with  laudable  pride 
the  future  glory  and  triumphs  of  preventive  medicine,  and  in  some  measure  realize  its 
vast  importance  and  grand  possibilities,  in  the  promotion  of  human  health  and  comfort 
and  the  prolongation  of  human  existence. 


TO  THE  MEDICAL  PROFESSION. 

Dear  Doctor : — In  accordance  with  the  request  of  Dr.  Joseph  Jones,  of  New  Orleans, 
La.,  President  of  the  Fifteenth  Section  of  the  Ninth  International  Medical  Congress,  I 
will  investigate  the  important  questions  embraced  under  Section  vi  of  the  Inquiries 
prepared  for  the  Council  of  this  Section  by  Dr.  Jones. 

In  order  to  throw  light  upon  these  important  questions,  I have,  upon  consultation 
with  the  President  of  the  Fifteenth  Section,  drawn  up  the  following  questions,  relating 
chiefly  to  the  effects  of  overflows  and  rice  culture  upon  the  public  health  ; and,  in 
order  to  obtain  reliable  information,  I address  the  following  inquiries  to  the  medical 
men  in  those  localities,  and  respectfully  request,  as  early  as  possible,  a full  and  specific 
answer  to  each  question. 

Question  1.  How  long  have  you  been  cognizant  of  the  results  of  overflows  of  the 
Mississippi  river  and  its  tributaries  upon  the  public  health  ? 

2.  Have  you  closely  observed  the  effects  of  said  overflows  upon  the  public  health  ? 

3.  Have  you  generally  or  uniformly  observed  an  increase  of  sickness  immediately 
succeeding  these  overflows  ? 

4.  If  so,  what  diseases?  Their  character  and  type? 

5.  "What  local  or  general  conditions  (including  topography)  have  you  noted  con- 
trolling or  modifying  the  effects  of  overflows  upon  the  public  health  ? 

6.  Have  you  kept  statistics  of  the  number  and  dates  of  these  overflows,  and  the 
cases  of  sickness  (if  any)  resulting  therefrom  ? If  so,  please  give  statistics. 

7.  What  is  your  experience  of  the  effects  of  rice  culture  upon  the  public  health? 
and  what  the  rate  of  death  per  1000  population  before  and  since  the  commencement 
of  rice  culture  ? 

8.  Has  malarial  hsematuria  increased  in  frequency  and  severity  during  the  past 
forty  years?  And  is  said  increase  due  to  the  increased  cultivation  of  rice  in  the  delta 
of  the  Mississippi  river,  or  in  other  localities  where  rice  is  cultivated  ? 

9.  What  effect  has  the  camping  and  working  of  State  prisoners  in  the  low  lands  and 
swamps  had  upon  said  prisoners,  held  by  Louisiana,  Arkansas,  Mississippi  or  other 
States  so  employing  their  prisoners  ? 

10.  How  many  deaths  have  been  caused  among  State  prisoners  by  malarial  diseases 
directly  traceable  to  exposure  to  the  malaria  of  the  swamps  ? 

11.  Give  facts  bearing  upon  the  relative  effects  of  overflows  and  rice  culture  upon 
the  colored  and  white  races. 

12.  Relations  of  drinking  water  to  the  health  of  the  inhabitants  of  rice,  sugar  and 
cotton  plantations.  Effects  of  swamp  water.  Effects  of  cistern,  well  and  spring  water, 
for  drinking  purposes. 

13.  The  best  means  of  protecting  tbe  health  of  the  laborers  and  inhabitants  in  such 
localities. 

The  physicians  of  the  valley  of  the  Mississippi  river  and  the  rice  regions  of  Arkan- 
sas, of  Alabama,  Georgia,  North  and  South  Carolina,  Florida  and  Texas,  are  earnestly 
requestly  to  furnish  their  replies  to  Richard  H.  Day,  m.d.  , 

Baton  Rouge,  La.  P.  O.  Box,  181. 

Please  answer  categorically. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  433 


DISCUSSION. 

Dr.  J.  A.  S.  Grant-Bey,  of  Egypt. — The  Nile  is  formed  by  the  White  and 
Blue  Niles,  about  2000  miles  from  its  mouth;  only  one  branch  between  that  aud  the 
Mediterranean  Sea,  the  Atbara,  being  only  a little  to  the  north  of  Khartoum,  at  the 
junction  of  the  White  and  Blue  Niles. 

For  a distance  of  upward  of  1500  miles  the  Nile  has  no  tributary,  and  for  the 
most  part  flows  in  a tortuous  manner,  over  many  cataracts,  through  a desert  country. 

Thus  tar  the  Mississippi  and  Missouri  joining  to  form  the  main  river  may  be 
compared  to  the  Nile,  and  the  yearly  overflow  takes  place  in  both  rivers;  but  in  the 
case  of  the  Nile  the  principal  and  rich  part  of  the  flood  comes  from  the  Blue  Nile, 
which  rises  in  Abyssinia,  and  brings  with  it  a fertilizing  mud  derived  from  the  disin- 
tegration of  granite  rocks. 

The  White  Nile,  which  comes  from  the  equatorial  lakes,  is  more  or  less  laden 
with  vegetable  matter;  but  this  has  little  effect  on  the  main  body  of  the  river,  which, 
although  veiy  muddy,  is  aerated  and  purified  as  it  passes  over  the  various  cataracts. 

It  is  only  along  the  northern  border  of  the  Delta  that  we  have  rice  culture,  but, 
although  it  is  said  that  about  one  in  ten  of  the  inhabitants  of  Egypt  is  affected  with 
haematuria,  I have  never  heard  of  malarial  haematuria.  The  haematuria  in  Egypt  is 
caused  by  the  haematobium  bilharzia,  a distinct  and  well-known  organism. 

We  have  malaria  in  the  swampy  parts  of  the  Delta,  but  it  takes  the  form  of 
ordinary  intermittent  and  remittent  fevers  unaccompanied  by  haematuria.  In  the 
rice-growing  districts  we  have  a prevalence  of  elephantiasis,  or  big  leg.  Of  course, 
in  the  Mediterranean  there  is  no  tide,  so  that  the  rice  fields  are  not  deluged  by 
freshets  from  the  sea,  but  the  rice  lands  are  more  or  less  salty. 

As  in  the  Mississippi,  so  in  the  Nile,  we  have  sometimes  a good  flood  and  some- 
times a bad  flood;  and  a bad  flood  may  be  from  excess  or  want  of  water;  both  are 
equally  disastrous. 

As  the  Nile  assuages,  toward  the  end  of  October,  we  often  meet  with  cases  of  what 
has  been  called  pernicious  fever,  but  I think  I may  say  that  English  practitioners 
out  there  consider  that  it  is  not  a specific  fever  in  itself,  but  is  the  result  of  some  other 
fever,  malarious  or  otherwise,  during  the  course  of  which  some  organ,  like  the  kid- 
ney, has  become  involved,  and  fatal  blood  poisoning  is  the  result,  probably  from  the 
formation  of  ptomaines. 

According  to  Sir  Wm.  Dawson,  the  Delta  of  the  Nile  cannot  be  much  more  than 
7000  years  old,  and  in  the  time  of  Herodotus,  some  450  years  B.  c.,  we  learn  that 
the  hippopotamus  was  quite  common  in  the  Delta,  showing  that  at  that  time  a great 
portion  of  it  must  have  been  marshy,  and  must,  therefore,  have  given  rise  to  diseases 
of  a malarious  character.  These  were  no  doubt  controlled  by  a perfect  system  of 
canalization  when  the  country  was  quiet,  but  when  in  an  unsettled  state  canals  would 
< be  neglected,  and  pestilence  would  be  the  result. 

It  was  pretty  much  in  this  state  that  the  great  Mohammed  Ali  found  it  in  1 806,  and 
it  is  to  his  energy  and  intelligence  that  we  owe  the  present  immunity  from  pestilen- 
tial diseases  of  an  endemic  character.  Mohammed  Ali  was  for  Egypt  what  St. 
Patrick  was  for  Ireland. 

As  to  the  colored  races  in  America  being  equally  liable  to  be  affected  by  malaria 
with  the  white  race,  I should  say  most  decidedly  that  it  is  not  so  in  Egypt,  if  I may 
be  allowed  to  substitute  the  Arab  for  the  negro. 

The  Arabs  are,  of  course,  more  exposed  to  malarious  influences  than  the  white 
races  in  Egypt;  still,  malaria  cannot  be  said  to  be  very  prevalent  among  them,  and 

Vo).  IV— 28 


» 


I 


434 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


perhaps  the  main  reason  lies  in  this  : that  they  live  more  naturally  than  Europeans 
— their  diet  is  spare  and  simple,  and  by  religion  they  are  total  abstainers. 

I should  like  to  know  what  Dr.  Day  means  by  an  insanitary  cultivation  of  rice.  ; 
I should  like  also  to  know  what  he  means  by  malarial  haematuria. 

Dr.  Maxwell  said — I am  much  interested  in  the  subject  of  Dr.  Day’s  valuable 
paper,  for  if  the  malarial  poison  were  eliminated  from  Florida,  where  I reside,  her 
citizens  would  enjoy  almost  complete  immunity  from  sickness.  Malarial  fevers  con-  1 
stitute  about  all  the  diseases  to  which  Floridians  are  subject,  and  though  they  are  j 
not  nearly  so  frequent  or  severe  as  the  outside  world  believe  and  charge,  those  forms  * 
of  disease  are  general,  and  require  treatment.  More  than  forty  years  ago  the  late  dis-  j 
tinguished  Dr.  M.  K.  Mitchell,  of  Philadelphia,  father  of  the  now  more  distinguished 
Weir  Mitchell,  in  lectures,  published  by  his  class,  in  1846,  expressed  the  idea  of 
a living  germ  as  the  probable  cause  of  malarial  fevers — an  inference  which  he  drew 
from,  among  other  circumstances,  the  close  relation  between  the  beginning  of  the  ’ 
rainy  season,  in  countries  where  the  line  between  the  dry  and  rainy  seasons  is  well 
defined,  and  the  appearance  of  malarial  fevers. 

Thirty  years  ago,  Prof.  Joseph  Jones,  our  distinguished  President,  demonstrated  | 
the  destructive  effect  upon  the  blood  of  malarial  diseases.  And  within  recent  years,  i 
Drs.  Klebs,  Tommasi-Crudelli  and  others,  have  shown  that  the  malarial  poison  is  1 
a microorganism,  which  destroys  the  corpuscles  and  other  important  elements  of  the  | 
blood,  and  thus  causes  the  fever,  and  the  resulting  anaemia.  They  have  shown, 
also,  that  heat,  moisture  and  oxygen  are  essentials  for  the  propagation  of  the  germs. 
This  fact  explains,  I think,  the  unhealthfulness  of  rice  culture.  It  is  not  that  there 
is  any  poisonous  emanations  from  the  rice  plant,  or  dangerous  chemical  changes  in 
the  soil,  for  Prof.  Joseph  Jones  and  others  have  demonstrated  that  chemical  results 
from  decaying  organic  matter  have  no  such  effects,  but  the  moist  condition  of  the 
soil,  from  the  fact  that  water  is  necessary  in  the  cultivation  of  rice,  heat  and  oxygen 
being  also  present,  gives  the  conditions  for  the  propagation  of  the  organism. 

Malarial  haematuria  is  the  most  severe  and  most  fatal  form  of  malarial  fever. 
This  is  because  haematuria  is  the  consequence  of  repeated  attacks  of  milder  forms  of 
the  disease.  I have  never  known  a case  of  haematuria  to  occur  with  the  first  parox- 
ysm of  fever  in  a previously  healthy  person.  Only  after  a succession  of  attacks,  the  I 
blood  meanwhile  becoming  less  nutritious  and  the  tissues  more  feeble,  does  haema-  \ 
turia  appear. 

I am  satisfied  that  the  free  use  of  mercury  contributes  to  the  production  of  the 
disease,  and  of  its  fatal  results,  for  the  same  effects  upon  the  blood  which  Dr.  Jones  I 
attributes  to  malarial  fever,  on  page  771  of  the  latest  edition  of  the  United  Staten  1 
Dispensatory , are  said  to  result  from  the  action  of  mercury.  Thus  the  fever  and 
mercury  mutually  contribute  to  produce  the  condition  of  blood  and  tissues  which, 
when  a congestive  paroxysm  supervenes,  terminates  in  the  so-called  haematuria. 

In  an  experience  of  forty  years  in  malarious  districts,  I have  never  in  a single 
instance  used  the  mercurials  or  other  cathartics  in  the  treatment  of  any  form  of  i 
malarial  fever,  and  to  that  fact  I attribute  my  good  fortune  in  not  having  had  a case  a 
of  malarial  haematuria  in  any  patient  whom  I have  treated.  My  experience  with 
the  disease  has  been  in  cases  that  have  either  occurred  in  the  practice  of  others,  or 
in  those  who  have  undertaken  their  own  cases,  but  in  every  instance  the  history 
shows  profuse  use  of  drastic  medicines. 

Dr.  Byrd,  of  Arkansas,  in  reply  to  Dr.  Maxwell,  said  that  in  his  experience  the 
gravest  form  of  malarial  trouble  was  haematuria.  He  disagreed  with  Dr.  31  ax  well  1 


_ — 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


435 


concerning  the  effect  of  calomel.  He  regarded  calomel  as  of  great  value  in  many 
cases  of  malarious  disease,  whether  acute  or  chronic.  He  had  never  seen  the  severe 
effects  attributed  to  its  action  by  Dr.  Maxwell. 

Dr.  Jones  said — Several  valuable  papers  are  at  hand  to  be  read,  and  I am  unwilling 
to  trespass  to  any  extent  upon  the  valuable  time  of  this  Section.  I cannot,  however, 
retrain  from  directing  the  attention  of  this  learned  body  to  the  remarkable  sanitary 
history  of  Savannah,  Georgia,  during  the  present  century. 

During  the  years  1856  and  1857  Dr.  Jones  made  a careful  examination  of  the 
medical  topography  and  mortuary  statistics,  and  presented  the  following  facts  illus- 
trating the  injurious  effects  of  rice  culture  on  the  health  and  longevity  of  the  white 
inhabitants. 

Savannah  is  situated  on  the  Savannah  river,  eighteen  miles  from  its  mouth,  on 
a sandy  plain,  elevated  forty-two  feet  above  half  tide.  On  the  north  this  plain  is 
terminated  abruptly  by  the  Savannah  river,  a turbid  stream  pursuing  its  slug- 
gish course  through  the  rice  fields  and  low  grounds  of  South  Carolina  and  Georgia. 
On  the  east  and  west  the  city  is  flanked  by  extensive  tide  swamps,  formerly  uudei 
wet  or  rice  culture,  at  the  present  time,  and  for  the  past  fifty  years  or  more,  under 
dry  culture. 

The  dry  culture  system,  by  thorough  drainage  of  paludal  districts  above  and 
below  Savannah,  and  of  the  islands  and  lands  immediately  across  the  river  in  front 
of  the  city,  was  instituted  in  1818. 

The  sandy  plain  extends  for  several  miles  beyond  the  city. 

Savannah,  therefore,  is  surrounded  on  all  sides  except  the  south  by  malarious 
districts.  In  fact,  up  to  1818  she  might  be  justly  regarded  as  a city  situated  in  the 
midst  of  a vast  marsh  or  rice  field,  reclaimed  by  a system  of  dams  or  embankments 
and  canals  from  its  original  condition  of  a rich  alluvial  swamp.  With  the  establish- 
ment and  perfection  of  the  dry  culture  system  and  of  the  draining  and  cultivation  of 
the  surrounding  low  lands,  the  health  of  Savannah  has  steadily  improved. 

Thus,  during  the  ten  years  from  1810-1819  inclusive,  during  the  wet  or  rice  cul- 
ture system,  the  deaths  among  the  whites  averaged  as  one  in  fourteen  of  the  white 
population. 

In  the  ten  years  from  1820-1829  inclusive,  the  deaths  were  in  the  ratio  of  one 
in  seventeen  of  the  entire  white  population;  and  in  the  ten  years  from  1830-1839 
inclusive,  as  one  in  twenty- four;  in  the  eight  years  from  1840-1847  inclusive,  as  one 
in  thirty-three. 

The  great  mortality  occasioned  by  fevers  referable  chiefly  to  the  action  of  heat, 
moisture  and  malaria  in  Savannah,  is  shown  by  the  fact  that  the  various  forms  of 
fever,  including  yellow  fever,  remittent,  intermittent  and  congestive  paroxysmal 
fevers,  occasioned  more  than  one-third  of  the  mortality  in  Savannah,  Georgia,  dur- 
ing a period  of  fifty  years,  1804-1853  inclusive,  or,  more  exactly,  4888  deaths  from 
the  various  forms  of  malarial  fever  and  other  fevers  in  a grand  total  of  14,332  deaths 
from  all  causes  in  the  white  inhabitants. 

Dr.  Jones  expressed  his  high  appreciation  of  the  great  value  to  medical  science  of 
the  paper  of  his  friend,  Vice-President  Richard  H.  Day,  of  Baton  Rouge,  Louisiana. 

Dr.  Day,  in  closing  the  discussion,  replied  to  the  inquiry  of  Dr.  Grant-Bey.  By 
an  insanitary  cultivation  of  rice  is  meant  the  plan  of  keeping  the  fields  covered  for 
long  intervals  with  stagnant  water.  The  improved  method  is  that  of  frequent  irri- 
gation with  fresh  water  at  intervals  sufficient  for  the  nutrition  of  the  rice. 

Malarial  haematuria  is  a blood  disease.  The  blood  is  in  a disorganized  condition 


436 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


before  hoematuria  is  manifested.  It  is  devoid  of  red  corpuscles.  A similar  disin- 
tegration of  the  red  blood  corpuscles  may  be  produced  by  the  injection  of  bile  acids 
under  the  skin.  The  bile  acids  are  retained  in  the  blood  by  reason  of  the  malarial 
poison.  The  haematuria  is  simply  a blood  disease  and  the  passage  of  disintegrated 
blood  through  the  kidneys. 


THE  HISTORY  OF  HYGIENE  IN  MODERN  EGYPT,  WITH  CRITICAL 
REMARKS  AND  PRACTICAL  SUGGESTIONS. 


L’lIISTOIRE  DE  L’HYGIENE  DANS  L’EGYPTE  MODERNE,  AVEC  DES  REMARQUES 
CRITIQUES  ET  DES  SUGGESTIONS  PRATIQUES. 


DIE  GESCHICHTE  DER  HYGIENE  IM  HEUTIGEN  EGYPTEN,  NEBST  KRITISCHEN  BEMER- 
KUNGEN  UND  PRAKTISCHEN  RATHSCHLAGEN. 


BY  J.  A.  S.  GRANT-BEY,  M.  D.,  LL.D.,  ETC.,  ETC., 
Senior  Surgeon  to  the  Egyptian  Government  Railways. 


For  a long  period  before  the  time  of  the  illustrious  Mohammed  Ali  (whose  reign 
dates  from  1811  to  1848  A.  D.)  both  personal  and  public  health  in  Egypt  must  have  sunk 
to  a very  low  ebb,  seeing  that  medical  matters  were  left  entirely  in  the  hands  of  reli- 
gious sheiks,  old  women,  barbers  and  bone  setters;  all  of  whom,  even  at  the  present 
day,  carry  on  their  art  with  considerable  eclat  among  an  ignorant  and  superstitious 
population.  There  were  no  doctors,  properly  so  called,  and  certainly  no  sanitary  service. 
Plague  and  pestilence,  of  one  kind  or  another,  were  continually  ravaging  the  country,  and 
no  pains  were  taken  by  the  government  of  that  time  either  to  prevent  or  cure  disease 
while  the  remedies  used  by  the  above-mentioned  medical  corps  were  not  of  a nature  to 
give  much  encouragement  either  to  the  sick  or  to  their  friends.  Most  of  these  remedies 
are  too  disgusting  to  record,  while  others  of  them  are  simply  superstitions. 

The  result  of  this  was  that  Egypt  was  looked  upon  by  the  whole  of  Europe  as 
unclean,  so  that  it  was  put  upon  a perpetual  quarantine  that  completely  ruined  its  com- 
merce. 

How  the  ancient  Egyptian  and  Arab  races  could  have  sunk  to  this  degradation,  after 
such  a brilliant  career  as  we  have  depicted  to  us  in  history,  can  only  be  understood  from 
the  knowledge  we  have  of  how  an  ignorant  and  tyrannical  race,  on  conquering  a more 
intelligent  and  civilized  one,  always  stifles  its  life  and  further  progress. 

When  Mohammed  Ali  succeeded  in  taking  the  government  of  Egypt  into  his  own 
hands,  he  must  have  had  a grand  field  for  introducing  improvements,  as  everything  was 
in  a chaotic  state.  He  showed  himself,  however,  quite  equal  fo  the  occasion,  so  that 
looking  back  from  this  date  (1887),  Mohammed  Ali  is  still  considered  the  father  of  the 
principal  and  most  beneficial  reforms  that  have  ever  been  introduced  into  Egypt. 

This  enlightened  ruler,  seeing  the  necessity  of  having  his  country  put  on  an  equal 
footing  with  European  nations  in  order  to  secure  its  prosperity,  among  the  other  reforms 
he  introduced,  sent  to  Europe  for  doctors,  who  formed  in  1825  a sanitary  service  * for 
the  cure  and  prevention  of  disease,  and  at  the  same  time  to  train  up  a number  of  the 
natives  (young  men  and  young  women)  in  the  medical  art.t  Their  success  was  very 


First  for  the  troops  and  then  for  the  civilians. 

f A number  of  young  natives  were  also  sent  every  year  to  different  European  countries  to 
study  medicine. 





SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  437 


marked  and  soon  began  to  bear  frnit  in  various  ways.  This  sanitary  service  has  con- 
tinued to  exist  ever  since,  under  different  names  and  with  varying  success,  but  the 
brightest  page  of  its  history  is  at  the  commencement  of  its  career.  It  had  been  in 
existence  but  a comparatively  short  time  when  Mohammed  Ali,  annoyed  at  the  per- 
petual quarantine  kept  up  against  the  different  ports  of  Egypt  by  Europe  and  Turkey, 
and  being  convinced  of  the  success  of  his  sanitary  service,  invited  Europe,  in  1846, 
to  send  a medical  commission  to  examine  into  the  sanitary  condition  of  his  country, 
with  the  view  of  having  the  quarantine  removed. 

In  answer  to  this  request  three  separate  and  independent  medical  missions,  respec- 
tively composed  of  French,  Austrian,  Turkish  and  Russian  physicians,  were  sent  to 
Egypt;*  and,  after  visiting  different  parts  of  the  country,  and  having  spent  ample  time 
at  the  various  places  visited  to  see  with  their  own  eyes  what  was  the  sanitary  state  of 
the  country,  they,  separately  and  independently,  sent  in  very  favorable  reports,  and 
proved  to  the  satisfaction  of  Turkey  and  Europe  that  plague  had  disappeared  from  the 
country,  and  that  there  had  not  been  a single  case  of  cholera  for  many  months,  f In 
those  days  this  was  considered  conclusive  evidence  that  neither  plague  nor  cholera  was 
endemic  in  Egypt,  so  the  oppressive  quarantine  was  removed,  and  Egypt  was  free  to  again 
develop  the  commerce  she  had  lost.  Time  proved  the  correctness  of  the  view  taken 
hv  Europe  of  the  opinion  of  the  three  medical  missions,  for  the  plague  has  not  again 
appeared  in  Egypt  since  1844,  and  cholera  only  at  lengthened  intervals,  being  always 
an  imported  malady. 

But  times  change  and  we  change  with  the  times,  so  that  in  these  latter  days  the 
commerce  of  Egypt  has  been  lost  sight  of,  and  British  politicians,  with  an  assiduity 
worthy  of  a better  cause,  have  compassed  sea  and  land  to  have  cholera  declared  an 
endemic  disease  of  Egypt,  $ with  what  intent  we  do  not  pretend  to  judge;  but  there  is 
no  difficulty  in  divining  what  would  have  been  the  immediate  result  if  Europe  had 
been  gained  over  to  this  unfounded  opinion.  Egypt  would  have  been  once  more  in  its 
dire  history  subjected  to  a perpetual  quarantine,  Europe  not  yet  being  ripe  for  doing 
away  with  this  most  unsatisfactory  and  ineffective  measure  for  preventing  the  spread  of 
a contagious  disease. 

In  order  to  give  some  plausibility  to  the  new-fangled  theory,  three  (the  traditional 
three)  separate  (not,  however,  independent)  medical  missions  were  resorted  to.  Of 
these  two  were  got  up  for  the  purpose  of  counteracting  the  widespread  opinion  that  the 
cholera  had  been  imported  into  Egypt,  and  the  third  for  the  purpose  of  discrediting  the 
discovery  of  Dr.  Robert  Koch,  who,  apparently,  demonstrated  to  the  world  at  large  and 
to  the  medical  profession  (not  tainted  with  politics)  in  particular  that  the  importation 
had  been  from  India. 

These  missions  were  as  follows: — 

1st.  The  mission  of  Oculist  Dutrieux  in  Egypt;  2d.  The  mission  of  Surgeon-gene- 
ral Hunter  to  Egypt;  3d.  The  mission  of  Drs.  Klein  and  Gibbes  to  India.  If  any  of 
these  missions  could  in  any  sense  be  called  scientific,  it  would  be  Dr.  Klein’s;  but  they 
had  each  and  all  of  them  to  work  up  to  a preconceived,  not  to  say  erroneous,  theory. 

We  all  know  what  has  been  the  fate  of  the  first  two  missions.  They  have  heen  dis- 
| credited  by  the  world  at  large,  and  time,  that  proves  all  things,  laughs  them  to  scorn; 


* Russian  mission,  in  1846.  French  mission,  in  1847.  Austrian  and  Turkish  mission,  in 
1849.  "(There  had  already  been  three  epidemics  of  cholera,  viz.,  1831,  1837,  1848. 

i If  cholera  were  endemic  in  Egypt,  then  surely  we  should  have  it  in  its  epidemic  form  every 
three  or  four  years,  just  as  in  India.  But  those  who  contend  for  its  endcruicity  have  yet  to 
admit  that  it  has  not  been  epidemic  in  Egypt  for  a period  of  seventeen  years,  viz.,  from  ,1865  to 
1883,  and  again  from  1883  to  present  date,  September,  1887.  But  arguments  and  facts  are 
thrown  overboard  when  they  stand  in  the  way  of  the  attainment  of  a political  aim. 


438 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


for  nearly  four  years  have  now  elapsed  since  the  cholera  epidemic  terminated,  hut  no 
more  cases  of  cholera  have  been  reported,  although  it  has  been  diligently  searched  for 
by  those  who  are  expected  to  favor  the  endemic  theory.  The  first  two  missions  referred 
to  were  made  to  have  a semblance  of  success  by  the  honors  that  were  heaped  upon  their 
leaders  and  abettors,  while  official  opponents  were  rewarded  as  is  usual  under  such  cir- 
cumstances. 

The  result  of  Klein’s  mission  was  not  so  well  known  at  this  time  as  that  of  the  two 
others  because  his  report  had  not  yet  been  made  public,  but  from  what  he  had  offi- 
ciously allowed  to  escape  from  his  lips  at  some  of  the  medical  meetings  in  London,  it 
appeared  that  he  wished  us  to  believe  that  he  had  entirely  upset  Dr.  Koch’s  comma- 
bacillus  theory,  as  the  same  comma  bacillus  had  been  discovered  vegetating  on  the 
gums  of  people  in  perfect  health  and  in  old  cheese,  as  well  as  in  other  diseases  besides 
cholera.  But  when  Dr.  Klein  was  taken  to  task,  it  was  clearly  brought  out  that  he 
had  not  employed  the  most  decisive  method  for  separating  one  kind  of  comma  bacillus 
from  another. 

He  had  used  his  microscope  to  good  purpose,  and  no  doubt  he  was  highly  gratified 
at  having  found,  as  he  thought,  the  Koch  comma  bacillus  under  circumstances  that 
precluded  its  having  any  connection  with  cholera.  Quod  erat  demonstrandum  ! ! ! 

There,  we  were  led  to  believe,  he  stopped  all  further  research,  as  he  thought  he  had 
gained  a complete  victory;  for  we  do  not  find,  after  his  demolishing  one  theory,  that  he 
had  another  to  put  forward.  All  was  reduced  to  chaos  once  more. 

For  some  unaccountable  reason  he  neglected  to  cultivate  (?)  the  apparently  undis- 
tinguishable  comma  bacilli.  Now,  it  is  inadmissible  that  such  an  able  investigator  as 
Dr.  Klein  should  have  been  ignorant  of  the  well-known  scientific  fact  that  it  is  only  iu 
the  artificial  cultivation  of  these  low  organisms  that  one  can  be  distinguished  from  the 
other  when  they  are  microscopically  alike  ; for  this  had  already  been  demonstrated  by 
Dr.  Koch.  Klein’s  mission,  therefore,  had  literally  fallen  short  of  effecting  its  pur- 
pose, and  the  only  thing  left  for  us  now  to  stand  by  is  the  unanimous  opinion  of  the 
three  separate  and  independent  medical  missions  sent  to  Egypt  during  the  cholera  of 
1883,  by  France,  Germany  and  Russia,  viz.,  that  cholera  is  not  endemic  in  Egypt, 
hut  is  always  an  imported  disease,  and  that  the  comma  bacillus  of  Koch,  he  it  the 
cause  of  cholera  or  not,  is  always  found  in  cholera,  and  in  no  other  disease  ; so  that, 
however  choleriform  the  symptoms  of  a case  may  be,  we  can  now  positively  assert  that 
it  is  not  true  cholera  if  the  comma  bacillus  of  Koch  is  not  found  in  the  dejecta  or  ejecta. 
This  being  admitted,  then  surely  no  one  will  deny  that  whatever  prevents  the  develop- 
ment of  the  cholera  comma  bacillus  will  also  prevent  or  cure  the  disease  indicated  by 
the  presence  of  that  organism. 

This  cholera  affair,  in  a politico-medical  point  of  view,  forcibly  reminds  us  of  the 
Suez  Canal  business  in  a politico-engineering  point  of  view.  It  was  England’s  most 
earnest  desire,  under  the  Palmerston  ministry,  that  the  projected  Suez  Canal  should  not 
be  dug,  so  she  sent  out  to  the  Isthmus  an  engineering  mission,  at  the  head  of  which  was 
a most  distinguished  engineer,  who  was  bound  to  find  that  the  canal  was  impracticable. 
This  engineer  acted  up  faithfully  to  his  instructions  ; nevertheless  the  canal  was  dug, 
and  something  deeper  than  “ fiat-bottomed  boats  ” now  sail  through  it,  while  Egypt  has 
not  become  “the  salt  marsh”  that  was  predicted.  No  one  who  knew  the  English 
engineers  could  for  a moment  doubt  their  capability  of  taking  accurate  levels,  yet  very 
little  credit  was  given  to  their  would-be-discovery,  in  face  of  the  opposite  results  of  the 
French  engineers. 

Now,  the  discovery  of  Oculist  Dutrieux  and  of  Surgeon-general  Hunter  is  just  on  a 
par  with  that  of  the  celebrated  English  engineers  ; no  one  outside  a very  narrow  polit- 
ical circle  believes  in  the  would-he  discovery  at  all,  hence  Egypt  has  not  been  subjected 
by  Europe  to  a perpetual  quarantine. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  439 


Had  the  erroneous  theory  emitted  by  the  above-named  gentlemen  been  generally 
believed  in,  it  would  have  had  a most  baneful  effect  on  the  commerce  of  Egypt,  and 
would  have  misled  the  profession. 

It  is  admitted  on  all  hands  that  after  the  death  of  Mohammed  Ali,  August,  1849, 
the  stimulus  given  to  the  medical  service  began  to  flag  under  the  Viceroy  Abbas  Pasha 
(January  1849  to  1854),  and  only  revived  again  for  a short  time  under  the  Viceroy  Said 
Pasha  (1854  to  1863),  and  again  under  the  ex-Khedive  Ismail  Pasha  (1864  to  1879), 
till  his  financial  difficulties  swamped  everything,  so  that  the  medical  service  was  ulti- 
mately rendered  powerless  l'or  want  of  money  even  to  pay  the  employes  with.  Under 
these  circumstances  sanitary  reforms  were  at  a standstill ; but  under  the  more  consid- 
erate rule  of  H.  H.  Tewfick  Pasha,  the  present  Khedive,  who,  more  than  any  Egyptian 
sovereign  of  his  line,  has  sacrificed  his  personal  interest  for  the  public  good,  the  med- 
ical service  has  been  reorganized  and  divided  into  two  distinct  departments,  by 
Khedivial  decree  of  3d  January,  1881 — a quarantine  department,*  with  its  headquarters 
at  Alexandria,  and  a Sanitary  Department, f having  its  headquarters  at  Cairo.  The 
Sanitary  Budget  was  also  increased  from  £54,000  to  £60,000  a year,  and  the  new 
arrangement  bade  fair  to  become  a success,  as  far  as  the  Sanitary  Department  was  con- 
cerned; for  under  the  able  presidency  of  H.  E.  Dr.  Salem  Pasha,  a large  medical  school 
was  built  near  the  Kasr  el  Ainee  hospital ; abattoirs  were  erected  at  Cairo,  Tantah, 
Mansoura  and  Portsaid.  Two  hospitals  were  built,  one  at  Mansoura  and  the  other  at 
Tantah,  the  intention  being  to  construct  two  hospitals  every  year  till  all  the  provinces  \ 
were  supplied  with  proper  hospital  buildings,  for  up  to  1881  all  the  government  hospitals 
were  simply  houses  that  had  been  built  for  some  other  purpose,  and  could  not,  there- 
fore, be  expected  to  fulfil  all  the  conditions  required  for  such  institutions.  Even  at  the 
present  time  Cairo  and  Alexandria  are  destitute  of  proper  hospital  buildings  belonging 
to  the  government,  notwithstanding  the  recommendation  to  the  government  by  the  late 
Sanitary  Board  to  have  a cottage  hospital  built  on  the  Kasr  el  Ainee  ground  (Cairo). 
Besides  that,  many  excellent  suggestions  for  the  good  of  the  public  health  were  made 
to  the  government,  that  retains  the  executive  power  in  its  own  hands,  but  few  of  them 
were  ever  carried  out. 

In  1882,  owing  to  the  Araby  rebellion,  every  administration  was  upset  for  several 
months,  and  scarcely  had  the  Sanitary  Board  got  into  working  order  again  when  a 
severe  epidemic  of  cholera  broke  out  (June  22d,  1883),  which  tried  the  strength  of  the 
Sanitary  Department  to  the  utmost.  But  no  one  can,  with  ahy  justice  or  truthfulness, 
deny  that  it  stood  to  its  work  manfully,  and  did  its  best  with  the  material  it  had  in 
hand.  Several  of  the  sanitary  doctors  and  some  of  the  hospital  nurses  contracted  the 
disease  while  attending  the  sick,  and  not  a few  of  them  died.  One  or  two  native  doc- 
tors were  accused  of  cowardice  and  neglect  of  the  sick,  aud  probably  the  accusation 
was  well  founded  ; but  in  more  civilized  countries,  no  doubt,  the  same  complaint 
might  just  as  truthfully  be  made.  As  the  epidemic  spread,  many  of  the  sanitary  doc- 
tors were  isolated  in  the  cordons  sanilaires,  and  thereby  the  Sanitary  Department 
became  crippled  in  its  resources,  and  had  to  accept  the  proffered  help  of  England,  so 
that,  some  time  before  the  epidemic  ceased,  a number  of  English  doctors  arrived,  who 


* The  duty  of  the  Quarantine  Department  was  to  guard  the  ports  and  frontier  towns,  so  as  to 
prevent  contagious  diseases  from  entering  the  country. 

f The  duty  of  the  Sanitary  Department  was  to  keep  the  country  in  a good  sanitary  condition, 
and  supply  all  the  medical  wants  of  the  country,  etc.,  etc. 

X Egypt,  for  governmental  purposes,  is  divided  into  fourteen  provinces.  Each  province  has 
its  hospital,  with  doctor  and  staff.  A chief  doctor  stay3  at  the  headquarters  of  the  governor  of  the 
province,  and  ho  has  under  him  so  many  doctors,  midwives,  veterinary  surgoons  and  barbers, 
according  to  the  number  of  villages  in  the  province. 


440 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


were  speedily  sent  to  the  infected  towns  that  stood  most  in  need  of  their  services. 
These  gentlemen  were  more  or  less  kept  in  hand  by  Surgeon-general  Hunter,  who  had 
been  sent  to  Egypt  by  Lord  Granville,  “for  the  purpose  of  investigating  and  reporting 
as  to  the  origin  of  the  cholera  and  the  best  means  for  its  repression.”  Surgeon-general 
Hunter  is  represented  as  a gentleman  having  “distinguished  general  and  medical 
attainments,  as  well  as  a special  experience  of  Oriental  maladies.”  However,  instead 
of  acting  up  to  his  public  instructions,  he  declared,  on  the  first  evening  of  his  arrival 
in  Egypt,  and  in  the  presence  of  a mixed  multitude  of  ministers  of  State,  army  officers, 
lawyers,  doctors,  etc.,  that  the  British  Government  had  sent  him  to  tell  them  that  the 
cholera  had  taken  its  origin  in  Egypt,  and  had  not  been  imported,  and  he  challenged 
any  one  to  contradict  him. 

Having  commenced  by  taking  this  stand,  one  could  easily  guess  in  what  groove  his 
investigations  would  run.  It  was  but  natural  to  suppose,  therefore,  that  he  would 
influence  the  newly-arrived  English  doctors  to  adopt  his  theory  without  any  more  inves- 
tigation than  he  had  carried  out  himself,  and  we  now  know  what  success  he  met  with 
in  this  respect  and  the  rewards  he  has  lavished  on  his  supporters. 

Dr.  Salem  Pasha,  however,  in  the  name  of  the  Sanitary  Board,  had  already  taken  up 
Dr.  Hunter’s  challenge,  and  the  Board  consistently  and  intelligently  upheld  its  opinion 
against  repeated  attempts  at  coercion;  but,  as  fate  would  have  it,  might  has  prevailed 
against  right. 

At  first  an  attempt  was  made  to  gag  the  Board,  but  this  having  failed,  it  was  sum- 
marily dismissed.  It  was  well  known  to  the  members  of  the  Board  for  several  weeks 
that  its  death  knell  had  sounded,  but  they  never  dreamed  that  treachery  would  be 
employed,  masked  by  a form  of  constitutional  procedure.  This  honorable  (!)  piece  of 
business  was  entrusted  to  a personage  who  had  only  a short  time  before  turned  Irish 
peasants  out  of  their  homes  in  the  middle  of  winter,  to  die  of  cold  and  hunger.  This 
was  just  the  sort  of  merciless  being  to  send  to  Egypt  to  carry  out  a coercive  policy,  and 
he  was  not  slack  in  acting  up  to  his  instructions;  for  on  the  13th  of  February,  1884,  by 
a mandate  signed  by  him,  and  by  him  alone,  the  Sanitary  Board  was  dismissed  in  a most 
arbitrary  manner,  and  with  censure  rather  than  with  thanks  for  past  services,  because, 
no  doubt,  it  had  committed  the  unpardonable  sin  of  maintaining  that  the  cholera  was 
not  one  of  the  endemic  diseases  of  Egypt.  When  the  death  warrant  was  served,  per- 
mission was  asked  by  the  Board  to  finish  their  report,  already  nearly  completed ; but 
this  was  denied  them,  on  the  ground  that  it  would  be  the  business  of  the  new  Board 
to  see  to  that.  Up  to  this  date,  however,  no  report  has  made  its  appearance,  and  the 
one  made  up  in  part  from  the  sanitary  archives  by  the  British  consul  at  Cairo,  and  sent 
home  to  the  Foreign  Office,  has,  it  is  to  be  feared,  been  suppressed;  for  nothing  has 
been  heard  of  it  since.  Notwithstanding  the  short  and  checkered  life  of  the  old  Sani- 
tary Board— extending  only  from  Jan.  3d,  1881,  to  Feb.  13th,  1884,  and  including  a 
rebellion  and  a cholera  epidemic — yet  it  could  point  to  a considerable  amount  of  good, 
honest  work,  achieved  under  most  trying  circumstances. 

A native  doctor,  President  of  the  Quarantine  Board,  who  had  fallen  upon  several 
devices  to  screen  himself  from  the  imputation  of  having  allowed  the  cholera  to  enter 
the  country,  was  one  of  the  most  clamorous  in  supporting  Dr.  Hunter’s  groundless 
theory  of  the  eudemicity  of  this  disease  in  Egypt,  and  he  was  rewarded  for  his  patron- 
age by  being  appointed  Director  of  the  new  Sanitary  Board,  with  an  Englishman  as 
sub-director. 

Twelve  months  had  scarcely  passed  when  the  government  had  to  dispense  witli  the 
services  of  both  these  gentlemen,  and  their  places  were  filled  up  by  a native  layman  and 
an  English  Army  Surgeon-major. 

After  a few  months  the  native  Director  resigned,  for  reasons  not  very  creditable  to 
the  service,  and  no  one  was  appointed  to  succeed  him,  so  that  the  English  Surgeon-major 


_.  . 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  441 


was  left  alone,  without  any  chief,  and  therefore  was  entirely  responsible  for  the  admin- 
istration of  the  Egyptian  sanitary  service. 

Lately  we  had  brought  to  our  notice  a most  useful  sanitary  measure  respecting 
infectious  diseases,  hut  it  was  pushed  forward  at  a very  inopportune  time,  with  the  result 
of  proring  a dead  letter.  If  the  sanitary  authorities  had  exhausted  every  available 
means  for  preventing  the  dissemination  of  infectious  and  contagious  diseases,  then  they 
might  expect,  and  would  certainly  deserve,  the  support  of  the  consuls  in  the  further 
prosecution  of  sanitary  measures  that  might  even  encroach  on  the  liberty  of  the  sub- 
ject. But  while  the  most  ordinary  sanitary  measures  are  neglected,  and  the  sanitary 
officers  themselves  have  not  the  confidence  either  of  the  public  or  of  the  profession,  it 
will  he  an  utter  impossibility  to  get  infectious  diseases  reported,  or  even  to  elicit  the 

1 sympathy  of  the  consuls  in  this  matter.  There  is  by  far  too  much  buzzing  and  confu- 
sion in  the  Egyptian  sanitary  hive  to  allow  of  a projected  measure  to  be  well  considered 
and  made  fit  for  launching  on  such  a number  of  communities  as  we  have  in  Egypt,  and 

(each  one  under  the  special  protection  of  its  consul,  who  has  always  at  hand  that  power- 
ful weapon  for  good  or  evil — the  capitulations. 

As  the  sanitary  sendee  is  now  administered  by  a comparative  stranger  to  the  coun- 
try, while  most  of  his  subordinates  are  without  any  sanitary  training,  we  are  not  at  all 
surprised  at  the  European  fangled  sanitary  measures  that  are  served  out  to  us  tale  quale , 
as  if  we  were  in  Europe  instead  of  in  Egypt. 

It  is  not  our  object,  however,  to  cavil  and  find  fault,  hut  rather  to  lend  a helping  hand 
in  preparing  the  ground  for  the  reception  of  the  excellent  measures  that  may  he  pro- 
posed from  time  to  time  by  the  sanitary  administration. 

It  has  also  been  our  endeavor,  in  as  popular  a way  as  possible,  and  through  the 
medium  of  an  Arabic  medical  journal,  to  enlighten  the  minds  of  the  Egyptian  public 
on  matters  that  concern  the  health  and  welfare  of  the  individual  and  of  the  nation  at 
large,  so  as  to  facilitate  the  universal  application  of  intelligent  sanitary  measures.* 
Could  we  effect  this,  we  should  have  no  dread  of  the  capitulations,  as  they  would  prob- 
ably never  be  appealed  to.  But  we  are  convinced,  from  personal  experience,  that 
public  measures,  however  well  devised  for  the  preservation  of  the  health  of  the  com- 
munity or  for  statistical  purposes,  can  never  be  officially  carried  out  unless  they  meet 
with  the  cooperation  of  the  people  themselves. 

It  is  with  the  view  of  securing  this  cooperation  that  we  call  the  serious  attention  of 
the  public  to  matters  that  are  of  vital  importance  for  the  health  of  the  individual,  the 
well-being  of  the  state  and  the  continuance  of  the  Egyptian  race.f 

In  a country  like  Egypt,  where  a European  civilization  has  been  grafted  on  without 
any  special  preparation  made  for  it,  and  where  it  drags  along  at  a slow  pace  and  is  only 
kept  from  being  entirely  inert  through  the  influence  of  foreigners,  it  must  strike  every 
reflecting  mind  that  an  earnest  effort  ought  to  be  made  to  educate  the  natives  up  to 
the  reforms  that  are  being  introduced  among  them. 

* To  effect  this  purpose,  a few  of  us  medical  men  practicing  in  Cairo,  both  native  and  European, 
have  formed  ourselves  into  an  editorial  committee,  and  have  for  the  past  eighteen  months  pub- 
lished a monthly  Arabic  medical  journal,  The  Shiffa,  in  order  to  fill  up  a felt  lacuna  in  the 
medical  education  of  the  country  and  to  keep  the  native  medical  practitioners  up  to  the  times. 
Dr.  Schme'il,  a Syrian  medical  man,  is  the  chief  editor.  The  articles  are  partly  original  and 
partly  excerpts  from  European  medical  journals. 

f For  the  past  eleven  years  a scientific  medical  journal,  The  Maqtalaf,  has  been  circulated 
pretty  considerably  in  Syria  and  in  Egypt.  It  is  edited  by  two  enterprising  Syrians,  Mr.  Nimo 
and  Mr.  Sariif,  and  among  its  articles  there  are  many  that  arc  moro  or  less  medical,  sanitary, 
etc.,  and  there  cannot  bo  the  slightest  doubt  that  literature  of  this  sort  published  in  the  Arabic 
language  materially  aids  the  authorities  in  carrying  out  measures  of  medical  and  sanitary  reform. 
The  medical  and  sanitary  articles  are,  as  a rule,  by  well-known  medical  men  in  the  East. 


442 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Much,  no  doubt,  is  being  done  by  way  of  encouraging  a love  for  knowledge  by  the 
many  schools  that  have  been  established  in  different  parts  of  the  country,  but,  we  fear, 
no  attempt  has  been  made  (by  the  government  at  least)  to  bring  home,  in  an  intelligent 
way,  to  the  native  mind  the  absolute  necessity  of  studying  and  conforming  to  the  laws 
of  health  in  order  to  control  sickness,  disease  and  death.  On  account  of  this  neglect 
the  application  of  some  sanitary  measures  has  been  frustrated  by  the  boisterous  rising 
of  the  natives  against  the  sanitary  officials.  This  would  never  occur  if  the  govern- 
ment were  careful  to  prepare  the  public  for  the  measures  to  be  carried  out ; and,  as  it 
is  the  duty  of  the  State  to  concern  itself  with  the  health  interests  of  the  people,  it 
must  employ  a special  class  of  persons  technically  acquainted  with  health  and  its 
requirements  for  man  and  beast— persons  whom  the  unskilled  general  public  can  iden- 
tify as  presumably  possessing  the  necessary  knowledge.  And  it  is  for  the  State  to 
make  this  knowledge  useful  to  the  community  and,  if  need  be,  to  prepare  the  com- 
munity for  its  application. 

The  State  is  not  called  upon  to  change  the  direction  of  the  wind  nor  the  course  of  a 
river,  but  much  might  be  done  to  have  the  air  kept  fresh  and  healthy,  and  the  water 
supply  pure,  and  to  prevent  the  criminal  diminution  of  the  population. 

When  no  special  epidemic  was  raging,  we  heard  little  or  nothing  about  dead  bodies 
being  thrown  into  the  Nile,  but  as  soon  as  a human  epidemic  manifested  itself,  then  our 
attention  was  attracted  to  what  may  have  been  undermining  the  health  of  the  inhabit- 
ants for  years,  and  the  health  department  had  to  bear  the  brunt  of  the  blame.  But 
was  it  the  fault  of  the  Board  of  Health,  seeing  that  it  had  no  power  to  execute  its  own 
rules  and  regulations  nor  the  necessary  influence  to  induce  the  government  to  execute 
its  suggestions  ? 

The  usual  excuse  given  by  the  government  for  not  carrying  out  a proposed  sanitary 
measure  is  the  want  of  money,  while  thousands  of  pounds  are  being  recklessly  spent  in 
paying  fraudulent  claims,  and  in  upholding  expensive  sinecures,  and  in  endeavoring  to 
tap  the  American  oil  wells  through  Gehel  ez  Zert  on  the  Red  Sea. 

Having  thus  exposed  the  position  of  the  Egyptian  sanitary  administration,  with 
special  reference  to  its  impotency  as  an  executive  power  when  not  backed  up  by  the 
government,  we  hope  that,  by  a careful  perusal  of  the  articles  we  have  already  com- 
menced to  publish  in  the  Arabic  language,  the  inhabitants  themselves  will  aid  the  sani- 
tary authorities  by  taking  the  initiative  in  carrying  out  simple  measures  for  home  and 
personal  healthiness,  as  may  be  suggested  through  a more  intelligent  understanding  of 
the  laws  of  health. 

This,  in  itself,  would  probably  urge  on  the  government  to  execute  the  larger 
measures  proposed  by  the  sanitary  administration  for  the  proper  cleansing  of  towns  and 
for  the  supply  of  pure  water  to  man  and  beast  throughout  the  country. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  443 
THE  PLACE  OF  SANITARY  SCIENCE  IN  EDUCATION. 

LA  PLACE  DE  LA  SCIENCE  IIYGIENIQUE  DANS  L’EDUCATION. 


DIE  STELLE  DER  SANITATSWISSENSCIIAFT  IN  DER  ERZIEIIUNG. 

BY  A.  W.  LEIGHTON,  M.D., 

Of  New  Haven,  Conn. 

IN  THE  FOLLOWING  PAPER  WILL  BE  BRIEFLY  SKETCHED  : 

(a)  The  history  of  a Human  Life,  and  note  its  bearing  on  our  educational  needs. 

(&)  Recall  the  character  impressed  upon  education  by  the  various  civilizations  of  the 
past,  and  in  the  light  of  such  past  experience  discuss  some  of  the  elements  of  strength 
and  weakness  in  our  American  civilization,  and  consequently  in  the  controlling  ideas 
which  dominate  our  education. 

(c)  Adhering  as  closely  as  possible  to  ways  and  means  already  established,  show  how 
these  various  educational  measures  may  be. utilized  and  gradually  modified,  so  as  prac- 
tically to  popularize  sanitary  notions,  both  in  their  personal  and  public  aspects,  with  the 
least  radical  changes,  and  with  due  recognition  also  of  the  claims  of  other  more  and 
even  less  important  training  and  interests. 

Guizot's  Law. — The  endeavor  to  formulate  the  experience  of  the  race  into  some 
pregnant  generalization  of  social  stability  culminated  in  Guizot’s  historical  analysis, 
isolating  the  very  essence  of  the  superiority  of  modern  European  over  ancient  civiliza- 
tions. He  showed  that  the  evolution  of  each  of  the  typical  phases  of  ancient  civiliza- 
tion was  controlled  by  some  dominant  principle,  by  some  preponderating  influence 
which  usurped  authority,  developed  society  in  subordination  to  itself,  and  determined 
the  character  of  all  things — institutions,  ideas  and  manners.  The  historian  also  showed 
that  this  domination  of  a single,  all-pervading  element  in  each  of  those  ancient  civili- 
zations was  the  original  germ  of  final  decay,  resulting  either  in  a state  of  chronic 
torpidity,  as  in  Phoenicia,  Egypt,  and  India,  or  in  a sudden  and  brilliant  development, 
as  in  Greece  and  Rome,  necessarily  attended,  however,  by  early  exhaustion,  and  fore- 
shadowing a proportionately  rapid  decline. 

On  the  other  hand,  he  showed  how,  from  the  very  cradle  of  our  own  civilization,  we 
have  been  accumulating,  in  unprecedented  number  and  variety,  strong  competitive  forces 
that  sway,  and,  above  all,  equilibrate  the  acts  of  men ; robust  ideas  which  have  served  not 
merely  as  the  watchwords  of  as  many  epochs,  but  which  survived  and  still  remain  living 
issues,  exerting  a perpetual  and  healthy  influence  upon  human  affairs. 

To  the  ancient  Roman  municipal  principle,  together  with  Roman  ideas  of  law  and 
order,  has  been  added  the  moral  and  political  influence  of  a mighty  Christian  corporation 
— the  Church.  Modifying  these  strong  forces  came  our  barbarian  heritage  of  a powerful 
sense  of  personal  liberty.  Then  came  the  separation  of  Church  and  State,  and  the 
principle  of  freedom  of  thought  and  conscience.  Later  sprang  up  art,  science,  litera- 
ture, political  rights,  socialism  and  other  elements  which  now  vie  with  the  ancient  forces 
of  monarchy,  aristocracy,  militaryism,  the  Church  and  each  other. 

In  modern  times,  and  particularly  in  this  country,  we  have  witnessed  the  birth  of 
yet  another  giant  force — the  industrial  spirit — whose  pristine  vigor  is  testing  the  physi- 
cal and  moral  stamina  of  men  as  never  before.  Andrew  White,  indeed,  applying 
Guizot’s  law  to  the  United  States,  attributes  to  this  all-absorbing  “mercantilism”  a 
despotic  tendency,  which  he  shows  has  already  become  inimical  to  other  and  better 
elements  of  our  civilization.  He  deplores  the  increasing  consecration  of  wealth  and 
brains  to  this  single  interest ; the  decline  of  true  patriotism,  the  backwardness  of 
science,  literature  and  the  arts  relatively  to  our  material  prosperity.  He  deplores  the 
obvious  effect  of  this  unchecked  motive  on  the  physical  development  of  our  people — 


444 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


“ the  hurry,  the  crush,  the  dying  out  of  families,  the  dyspeptic  type  which  enables  an 
American  to  he  recognized  in  any  country.”  In  fact,  he  concludes  that,  notwithstanding 
the  elements  of  soundness  which  we  share  in  common  with  the  strongest  nations  of 
Europe,  we  are  still  liable  to  retrograde  through  greed  and  its  accompanying  corrup- 
tion, indifference  and  physical  degeneracy. 

It  is  becoming  clearer  every  day  that  the  necessity  underlying  Guizot’s  law  grows 
directly  out  of  the  natural  complexity  of  our  organization,  which  will  not  for  long 
brook  indifference  to  a single  vital  interest.  Let  it  be  noticed  also,  that  the  richly 
diversified  complexion  of  modern  life,  largely  necessary  though  it  he,  the  enormous 
aggregation  into  cities,  the  intensified  struggle  for  existence  and  for  preferment,  the 
hitherto  impossible  inter-communication  throughout  the  world,  have  brought  greatly 
increased  risk  to  the  integrity  of  the  organism  itself,  and  rendered  imperative  a broader 
revival  than  was  every  necessary  in  the  past,  of  an  instinct  which  in  our  age  has  always 
been  relatively  weak — the  instinct  of  self-preservation  enlisted  as  an  enlightened  com- 
petitive force,  proportionate,  at  least,  to  the  magnitude  of  the  role  which  health  plays 
in  the  fruition  of  all  other  interests. 

Whatever  conceptions  dominate  society,  whether  narrow  or  liberal,  or  whatever  ele- 
ments of  character  are  believed  to  be,  on  the  whole,  most  advantageous,  must  early 
concern  education  as  a means  of  developing  these  advantages.  It  is,  no  doubt,  true 
that  the  direction  impressed  on  education  has  always  depended  upon  the  ruling  motives 
of  the  day — upon  the  ideas  which  society  formed  of  the  perfect  man  or  of  the  repre- 
sentative man  of  the  times. 

“Among  the  Romans  it  is  the  brave  soldier,  the  orderly  citizen,  yielding  to  disci- 
pline; among  the  Athenians  it  is  the  man  who  unites  in  himself  the  happy  harmony  of 
moral  and  physical  perfection;  among  the  [ancient]  Hebrews  the  perfect  man  was  the 
pious,  virtuous  man,  who  should  be  capable  of  attaining  the  ideal  traced  by  God  him- 
self in  these  terms:  ‘Ye  shall  be  holy,  for  I the  Lord  your  God  am  holy.’  ” * 

For  further  illustration,  witness  a later  period.  With  Christianity  came  the  ideal 
of  a man  scorning  this  world,  with  eyes  fixed  on  the  life  to  come,  naturally  resulting 
in  a culture  almost  exclusively  religious  and  moral.  The  absolute  sufficiency  of  the 
Scriptures  stifled  free  inquiry,  imprisoned  education  in  the  Church,  and  gave  to  it  an 
austerity  and  narrowness  never  realized  in  the  older  systems.  In  fact,  the  sway  of  this 
ideal  was  more  disastrous  in  results  to  education  and  to  the  whole  character  of  life  than 
the  previous  conceptions  of  the  pagans  had  been,  and  before  the  world  could  be  aroused 
from  the  lethargy,  the  indifference  to  the  body,  and  the  contempt  for  this  life  thus  pro- 
duced, centuries  were  ruthlessly  squandered  on  this  supreme  absurdity,  and  the  gloom 
of  the  dark  ages  seemed  bent  on  forever  obliterating  the  light  of  all  previous  human 
experience. 

Indeed,  while  recognizing  our  indebtedness  to  this  period  for  some  of  the  germinat- 
ing forces  of  the  modern  world,  we  must  also  notice  that  to  this  ascetic  age  can  be 
traced  the  tap-roots  of  a multitude  of  our  popular  prejudices — of  our  dimness  of  per- 
ception where  simply  the  health  side  of  morality  is  concerned,  of  our  ingrained  apathy 
to  this  particular  class  of  selfish  interests,  of  our  reluctance  to  incur  expense  in  warding 
off  calamity  still  half  believed  to  be  providential.  Furthermore,  our  continued  resig- 
nation to  invalidism,  and  to  a suggestively  fluctuating  death  rate,  exposes  our  lineage 
and  our  ancestral  contempt  for  the  prudential  virtues,  reveals  our  tardy  progress  in 
these  respects  since  the  days  when  the  body  was  esteemed  an  enemy  of  the  soul,  when 
even  personal  and  domestic  cleanliness  and  decency  were  proscribed  as  worldly,  and 
when  the  resulting  ravages  of  plague  and  physical  disorder  were  hoped  and  believed  to 
be  warded  off  and  charmed  away  by  amulets  and  prayers. 

“L’oducation  et  1’instruction  ehez  les  aneieus  Juifs.” 


* J.  Simon. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  445 


From  the  renaissance  of  learning,  however,  can  he  observed  the  promise  of  a better 
public  opinion  and  of  rational  aims  for  education.  The  revival  of  interest  in  the  artistic 
and  philosophical  treasures  of  Athens  and  Rome,  so  long  buried  under  the  priestly  ban, 
besau  to  reexcite  a normal  interest  in  this  life,  and  to  restore  some  traces  of  the  old 
classic  respect  and  care  for  the  body.  The  rapid  circulation  of  ideas  after  the  invention 
of  printing,  and  the  proportionate  stimulation  of  modern  thought  and  scientific  inquiry, 
especially  the  biological  inquiry  of  the  last  two  decades,  has  enlarged  our  knowledge 
of  hygiene  far  beyond  what  the  Greeks  possessed  or  had  occasion  to  teach.  But  the 
complicated  conditions  of  life  now  actually  demand  this  larger  knowledge  of  facts,  and 
the  fiercer  rivalry  that  characterizes  the  times  requires,  as  we  have  said,  a correspond- 
ingly forcible  impulse,  as  a compensating  element  to  limit  other  strong  impulses,  to 
offer  a secular  check  to  the  excessive  modern  reaction  against  moral  training,  to  curb 
some  of  the  murderous  tendencies  of  greed  and  the  suicidal  tendencies  of  ambition,  to 
elevate  and  give  a new  significance  to  the  idea  of  citizenship,  to  the  idea  of  municipal 
government  and  to  the  idea  of  international  brotherhood.  This  social  and  moral  aspect 
of  sanitation  constitutes  its  chief  claim  upon  public  education,  while  its  paramount 
importance  to  the  individual  should  give  it  a conspicuous  place  in  any  liberal  education. 

But  let  us  next  examine  the  individual  aspect  of  sanitary  science;  for,  after  all,  the 
natural  history  of  a single  organism  must  furnish  the  principal  guiding  aud  limiting 
data  from  which  to  judge  of  the  times  and  specific  uses  of  sanitary  training. 

Organic  Data. — The  infant  enters  this  world  a delicate  animal,  the  miniature  of  a 
man  structurally — not  quite  a miniature  mentally,  but  possessed  of  a variable  stock  of 
inherited  tendencies  and  possibilities.  The  chief  feature  of  the  problem  before  this 
organism  is  growth — rapid  growth — for  twelve  to  fourteen  years,  and  thereafter,  by 
progressively  diminishing  increments,  it  must,  practically,  reach  a maximum  in  about 
twenty-one  years.  The  child  must  do  more  than  simply  grow.  The  quick  circulation 
of  blood  through  its  tissues,  its  active  respiration  and  its  voracious  appetite  are  neces- 
sitated by  the  direction  of  its  metabolism  chiefly  to  surplus  constructive  ends  and  to  the 
accumulation  of  a surplus  capital  of  latent  or  potential  energy,  stored  away,  by  means 
no  longer  mysterious,  in  the  growing  tissues,  for  future  and  often  sudden  expenditure 
in  the  development  or  exercise  of  faculty. 

Thus,  during  the  early  manifestations  of  intelligence,  the  primary  law  of  growth 
asserts  itself,  and  for  the  first  score  of  years  the  chief  function  of  our  hearty,  fat  and 
jolly  little  vertebrate  should  be  unimpaired,  luxurious,  bodily  development. 

The  first  half-dozen  years,  with  their  reflex  enjoyments,  irritations  aud  dangers,  are 
the  parents’  absolute  charge.  It  is  exclusively  to  the  previous  training  of  parents  and 
of  their  authorized  agents,  not  to  the  child’s  intelligence,  that  we  must  look  for  the 
conditions  of  a sounder  childhood — for  the  promise  of  an  undamaged  nervous  structure, 
of  a more  permanent  dentition,  and  of  an  unimpaired  digestive  and  excretory  function. 

The  next  half  dozen  years  preceding  puberty  realize  the  culmination  of  the  senses 
of  touch,  sight,  hearing,  taste  and  smell . There  is  now  a general  sensuous  acuteness 
which  becomes  blunted  in  later  years.  The  eye,  which  gives  us  fully  one-half  of  our 
practical  information,  is  now,  according  to  the  physiologists,  at  its  dioptric  prime,  when 
its  media  are  clearest  and  its  muscular  mechanism  most  mobile.  From  six  to  twelve 
is  the  age  of  maximum  pure  memory,  unaided  by  artificial  tricks  or  associations. 

The  object  of  this  early  acuteness  is  clear.  It  announces  the  commencing  limits  of 
parental  care,  when  the  child  must  begin  to  maintain  for  himself  and  for  herself  inde- 
pendently the  conditions  of  life,  which  are  by  no  means  simple. 

The  foundations  of  the  concept! ve  faculty  and  of  the  j udgment  are  now  being  laid 
upon  rock  or  sand,  according  to  the  character  and  variety  of  the  experiences  permitted 
and  enjoined.  If  adequate  notions  have  ever  been,  or  shall  ever  be  entertained  by 
young  men  aud  women  upon  any  timely  subject,  there  must  first  be  au  initial  intro- 


446 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


duction  to  a variety  of  things,  simple  phenomena,  and  elementary  ideas  underlying 
this  subject,  and  out  of  which  the  conceptions  are  to  be  built  as  a structure  is  built 
out  of  bricks.  The  early  aud  marvelous  development  of  an  exquisitely  sensitive 
and  retentive  nervous  apparatus  equips  the  young  to  rapidly  accumulate  the  useful 
bricks,  if  only  they  are  brought  face  to  face  with  the  right  material.  Hence,  observa- 
tion, instruction,  description  and  comparison  should  be  directed  to  the  data  underlying 
the  first  concerns  of  life.  These  latter  are  an  ability  to  earn  and  to  lead  an  independ- 
ent existence,  an  ability  to  maintain  health  as  perfectly  as  is  compatible  with  necessary 
independence,  an  ability  to  recognize  and  respect  the  interests  of  others,  and  to  ennoble 
aud  render  life  pleasurable. 

Herein  lies  the  necessity  of  jealous  selection,  which  is  intensified  by  the  fact  that 
the  brain  has  only  a limited  capacity.  Herein  lies  the  wisdom  of  so  guiding  these 
early  introductions  to  the  concrete,  and  of  so  handling  children’s  common  occupations 
and  studies  as  to  suggest  and  enforce  those  particular  truths  which  they  will  first  need 
to  know. 

Eefore  arriving  at  any  separate  treatment  of  sanitary  training,  we  ought  already  to 
appreciate  the  general  tenor  and  spirit  of  education  as  applied  to  the  ends  above 
described. 

The  occurrence  of  puberty  at  the  twelfth  to  the  fourteenth  year  marks  the  dawning 
of  faculties  that  at  once  begin  to  play  a controlling  part  generally  underrated  by  all 
save  the  doctors,  whose  revenues  tally  with  the  accumulation  of  clinical  evidence  on 
this  point.  There  is  now  a sudden  and  imperative  diversion  of  much  of  the  latent 
energy  acquired  from  food  to  increased  and  new  constructive  and  developmental  ends. 
Puberty  inaugurates  the  first  epoch  that  is  conspicuously  beset  with  accidents  peculiar 
to  the  child’s  own  volition  and  considerably  beyond  parental  care;  involving  more  or 
less  permanent  impairment  of  adult  health  and  mental  tone.  The  directions  in  which 
the  child’s  intelligence  is  now  led  are  a truer  augury  of  adult  soundness  than  of  future 
business  or  other  capacity;  subordinate  only  to  the  ominous  consideration  that  his  ances- 
try—the  invisible  artisans — are  moulding  and  grinding  him  slowly  but  steadily  into 
their  own  similitude. 

The  untutored,  ambitious  and  ignorant  practices  which  young  people  stumble  into, 
or  acquire  from  positive  misguidance,  are  capable  of  stunting  growth  aud  diverting 
vital  euergy  into  useless  channels  or  worse.  This  fact  applies  especially  to  girls, 
because  puberty  is  for  them  a far  more  sudden  process,  and  there  should  be  allowed  for 
them  a far  larger  margin  of  energy  undiverted  from  the  normal  occupation  of  simply 
physical  development.  Puberty  is  the  favorite  starting  point  of  vicious  habits;  the 
physical  import  of  some  of  which,  though  occasionally  considerable , has  been  grossly 
exaggerated  in  the  case  of  boys,  and  this  exaggeration  has  been  forced  to  holster  up  a 
monstrous  superstition  and  a proportionately  outrageous  quackery  that  thrives  and 
fattens  out  of  the  pockets  of  the  foolishly-alarmed  and  misinformed;  while,  strange  to 
say,  the  moral  deformity  ofteu  acquired,  aud  of  which  the  physical  is  usually  but  a 
trifling  incident,  has  been  universally,  nay,  religiously  ignored.  Alcohol  and  tobacco 
manliness  asserts  itself  at  this  age,  when,  unfortunately,  the  system  is  most  susceptible 
to  the  harmful  effects  of  these  drugs. 

The  necessity  of  allowing  for  the  preoccupation  of  the  vital  powers  for  the  few  years 
including  puberty,  applies,  as  I have  said,  chiefly  to  the  female;  the  phenomena  in 
hoys  being  far  more  gradual,  are  of  less  significance  so  far  as  developmental  dangers 
are  concerned. 

Early  death  ofteu  has  its  compensatory  advantages;  but  permanent  damage  or 
maiming  from  unnecessary  exposure  or  unseasonable  indulgence  in  acts  perhaps  harm- 
less enough  in  themselves,  has  no  bright  side;  yet  the  perusal  of  a physician’s  ledger  oi 
note-book  would  reveal  how  frequently  chronic  troubles  can  be  traced  back  to  this 


SECTION  XV — rUBLIC  AND  INTERNATIONAL  HYGIENE.  447 


epoch  when  young  folks  are  being  thrown  upon  their  own  resources,  and  are  beginning 
to  test  the  quality  rather  than  the  quantity  of  their  training. 

Among  the  diseases  which  most  frequently  date  back  to  this  age  of  increasing  inde- 
pendence of  action  are  to  be  enumerated  chorea,  hysteria,  epilepsy,  headache,  worry, 
insomnia  and  other  neuroses  wholly  or  partly  of  reflex  origin;  all  frequently  involving 
an  hereditary  element,  but  yet  largely  dependent  on  over-excitation  of  the  brain  and 
spinal  cord.  The  penance  of  permanent  pelvic  or  uterine  derangement  is  often  unwit- 
tingly contracted  for  by  the  untrained  novitiate  of  womanhood.  Chlorosis  and  consti- 
pation, also;  the  latter  in  girls  commonly  arising  from  an  inhibitory  influence  on  the 
rectum,  emanating  from  the  tender  and  swollen  ovaries  and  womb.  In  both  sexes  con- 
stipation and  its  sequel ;e  are  ultimately  to  be  attributed  to  neglect  of  physiological 
information  and  to  popular  errors  regarding  the  use  of  purgatives. 

A geueral  want  of  recognition  of  the  glandular  activity  of  puberty  frequently  under- 
lies chronic  tonsillitis,  acne,  and  scrofula.  A strong  predisposition  to  the  last  of  these 
is  doubtless  often  inherited,  but  it  cannot  be  too  emphatically  stated  that  about  one-half 
of  the  cases  investigated  are  found  to  be  acquired  de  novo,  or  superinduced  by  needlessly 
faulty  hygienic  conditions  or  extreme  poverty. 

While  weathering  puberty,  the  vast  majority  are  forced  from  school  into  self-sup- 
porting occupations,  where  competition  soon  gives  the  preference  to  preliminary  fitness 
and  health.  This  phase  of  youth  suggests  another  critical  test  of  the  times  and  nature 
of  early  education. 

We  now  approach  the  age  of  voracious  reading  instincts,  when  it  is  apparent  how 
this  boon  which  society  is  so  anxious  to  give  everybody  is  to  be  used.  It  is  indeed  a 
[ sad  reflection  that  multitudes  who  could  read  prefer  to  spend  their  leisure  in  idleness  ; 
s also,  that  the  ease  with  which  literature  really  finds  its  way  into  the  hands  of  the 
. laborer  does  not  keep  pace  with  his  ability  to  read. 

But  what  of  the  literature  of  those  who  do  read  ? The  cheap  novelette  and  the 
newspaper  are  confessedly  created  on  business  principles,  to  supply  a popular  demand 
for  amusement  and  gossip,  not  to  elevate  this  demand.  The  periodicals  and  books 
i found  in  the  homes  of  the  well-to-do  comprise  everything,  good  and  bad.  Both,  how- 
't  ever,  are  on  the  whole  over-stimulating,  and  almost  equally  lacking  in  all  that  might 
i create  an  incentive  to  right  living.  For  the  great  army  of  young  people,  a desire  to 
i read,  to  continue  and  benefit  by  their  elementary  advantages,  might  be  encouraged  by 
the  evening  continuation  schools,  and  the  correspondence  schools,  both  of  which  are, 
however,  but  in  the  infancy  of  their  usefulness. 

Besides  bread-winning,  we  find  the  years  succeeding  puberty  busily  occupied  with 
all  the  fun  that  is  going  on,  innocent  fun,  for  the  most  part.  I am  not  going  to  indict  young 
i America  with  pessimistic  tendencies.  Suffice  it  here  to  recall  the  fact  that  wherever 
the  spontaneous  enjoyment  of  sport  involves  real  moral  danger,  there  we  shall  almost 
invariably  discover  a lack  of  apprehension  of  what  constitutes  a physical  sin.  Point 
1 out  the  man  who  belittles  the  indiscriminate  sowing  of  “wild  oats,”  and  we  shall  dis- 
i cover  an  ignoramus  who  believes  that  an  occasional  gonorrhoea  is  “healthy,”  cleansing 
the  blood  of  unhealthy  humors,  just  as  firmly  as  he  believes  that  the  odors  from  dogs  and 
i barnyards  are  healthy,  or  that  amber  or  some  other  amulet  can  ward  off  disease. 
I Wherever  the  infected  prostitute  is  freely  permitted  to  ply  her  trade,  with  no  public 
precaution  to  prevent  innocent  wives,  children  and  nurses  from  suffering  the  conse- 
* quences  of  the  licentiousness  of  others,  there  we  shall  find  ignorant  lads  whose  sorry 
: plight  is  the  standing  universal  joke  ; lads  who  little  reckon  on  the  harvest  which  even 
4 they  themselves  are  to  reap  in  later  years. 

Some  time  before  physiological  maturity,  the  young  wife  or  maid  makes  her  first 
1 serious  attempt  at  cookery,  housekeeping,  and  the  care  of  children.  This  is  no  longer 
a matter  of  mud  pies  and  rag  babies.  From  the  very  outset  weighty  interests  depend 


448 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


upon  immediate  success  or  failure.  The  contentment  and  health  of  husband  and 
children,  as  well  as  her  own,  may  be  at  stake,  and  at  once  dependent  upon  her  knowl- 
edge and  training.  No  matter  what  she  may  have  studied,  that  only  will  conspicuously 
help  her  uow  that  enables  her  to  nourish,  warm  and  ventilate  a healthy  infant— that 
prevents  her  murdering  good  food  materials.  I have  often  been  struck  with  the  sur- 
prisingly fair  appearance  of  fish,  meat,  vegetables,  and  other  food  stuffs  that  are  exposed 
for  sale  in  the  poorest  quarters.  Frequent  as  are  the  exceptions  to  this  rule,  one  can 
hardly  conceive  of  the  black  art  that  everywhere  contrives  to  convert  fresh  and  whole- 
some provisions  into  the  vilest  of  messes.  The  children  are,  of  course,  the  chief  sufferers 
on  this  account,  but  the  husband  will  generally  prosper  directly  as  the  wife  foresees  the 
dangers  that  beset  lier’s  and  the  children’s  health. 

Our  coy  maiden  has  perhaps  acquired  at  school,  or  through  the  rivalry  of  compan- 
ions, the  power  of  postponing  her  alvine  and  renal  evacuations  for  incredible  periods, 
the  former  often  for  weeks.  She  has  also  cramped  her  breathing  power,  forced  her 
pelvic  viscera  as  far  downward  as  they  will  conveniently  go,  danced,  bathed,  and  other- 
wise exposed  herself  at  those  times  when  harm  was  likely  to  result.  And  now  she 
adds  to  such  talents  the  traditions  of  married  women — that  abortions  are,  of  course, 
trivial  affairs,  which  may  safely  be  induced  by  tansy  and  turpentine  ; that  confinement 
should  be  followed  by  a purge,  but  that  fish  must  not  be  eaten  during  convalescence,  as 
a woman  values  her  life.  Other  traditions  pertain  to  the  care  of  infants,  and  had  best 
be  omitted.  Nothing  is  more  common  in  general  practice  than  to  see  invalids  starving 
on  beef  tea  (wash),  or  sick  infants  nursed  with  a diet  of  corn  meal  or  cracker  water. 
Young  children  are  often  fed  with  tea,  coffee,  beer,  and  coarse  adult  food.  An  idea 
prevails  among  Northern  mothers  that  an  icy  bed  room  toughens  the  shivering  children, 
and  that  “night  air  ” must  not  be  admitted  into  even  a hot  chamber.  The  indiscrimi- 
nate resort  to  quack  nostrums  now  begins  to  be  a feature  of  unenlightened  domestic 
economy,  and  the  wretched  consequences  are  to  be  attributed  far  less  often  to  direct 
toxic  action  than  to  the  fooling  away  of  valuable  time  when  effective  measures  might 
have  been  taken,  according  to  the  indications  of  a correct  diagnosis.  When  woman 
performs  the  functions  of  nurse,  perhaps  under  medical  direction,  the  lives  of  those 
dearest  to  her,  the  lives  of  all,  at  one  time  or  another,  are  at  the  mercy  of  her  intelligent 
cooperation,  of  her  ignorance,  dullness  or  pig-headed  obstinacy. 

Our  newly  made  voter,  meantime,  forms  many  crude  and  a few  respectable  political 
notions,  and  long  before  these  are  a credit  to  him  he  exercises  his  franchise.  If  he  is 
often  ignorant  and  gullible  in  general  politics,  he  is  particularly  so  in  all  that  relates 
to  public  sanitation,  and  this  delect  follows  him  into  the  “common  council  ” and  into 
the  “ aldermanic  board.”  Nevertheless,  it  is  universally  admitted  that  the  health 
authorities  can  never  become  efficient  until  they  obtain  fairly  intelligent  cooperation  on 
the  part  of  citizens. 

In  brief,  at  the  age  of  maturity,  both  men  and  women  have  essayed  most  of  the 
experiences  of  life.  All  have  advanced  through  certain  orderly  increments  of  growth, 
and  have  displayed  the  principal  functional  activities  and  tissue  metamorphoses.  AH 
have  run  the  worst  of  the  gauntlet  of  disease,  along  which  the  majority  of  their  fellows 
have  fallen,  and  surviving,  are  now  destined  to  hear  onward  clinical  proof  of  the  vari- 
able extent  of  protection  afforded  by  parents,  teachers  and  a feeble  and  uneducated 
natural  instinct.  The  faculties,  both  physical  and  psychical,  have  developed  apace, 
and  the  relative  vigor  of  these  powers  is  not  thereafter  to  he  materially  altered.  The 
majority  have  instinctively  ventured  the  marriage  or  similar  relations,  and  their 
tissues,  minds  and  morals  are  to  carry  through  life  the  impress  of  these  experiences, 
whether  happy  or  vicious.  With  a certain  freedom  of  choice  practically  within  narrow 
limits,  all  have  necessarily  been  forced  into  occupations  and  into  social  conditions 
which,  as  a rule,  they  are  thenceforth  to  re  bun.  In  various  senses,  the  characters  of 


SECTION  XV — rUBLIO  AND  INTERNATIONAL  HYGIENE.  449 


that  particular  generation  have  been  determined  ; and  it’  it  shall  surpass  the  previous 
one  in  health,  in  richness  and  variety  of  thought,  or  in  morals,  it  will  he  chiefly  owing 
to  causes  operating  previous  to  maturity — causes  hereditary  and  educational.  After 
life  may  he  principally  concerned  in  perfecting  aud  consolidating  the  man  along  lines 
of  development  already  marked  out;  but,  the  chimeras  of  educational  enthusiasts  aside, 
aud  with  due  recognition  of  the  iron  hand  of  heredity,  we  have  still  left  to  us  the 
fact,  of  the  most  practical  if  not  of  supreme  importance,  that  physiological  adolescence 
was  preeminently  the  plastic  age.  Afterward  comes  the  long  swell,  culmination,  and 
decline  of  human  energy,  hut  always,  however,  accompanied  by  progressive  rigidity  of 
tissues,  habits,  and  prejudices. 

If  it  were  true  that  parental  care,  a knowledge  of  the  three  R’s,  ordinary  observa- 

Jtiou,  and  contact  with  the  world  could  successfully  anticipate  the  various  vital  phases 
of  life  as  they  arise; — could  in  fact  suffice  for  timely,  efficient,  and  relatively  economi- 
cal education,  little  further  need  be  said.  But  the  facts  are  that  home  training  too 
often  perpetuates  the  faults  and  narrow  family  traits  of  parents  which  should  be  cor- 
rected aud  liberalized  by  contact  with  other  teachers,  other  ideas  and  examples;  while, 
again,  systematic  education  has  not  anticipated  the  critical  occasions  for  its  utility. 
Some  particular  kinds  of  intelligence  needed  at  once  in  early  life  have  been  discrimin- 
ated against,  while  many  others  that  are  not  at  all  necessary  until  later  years,  if  ever, 
have  received  the  preference. 

The  fact  is  that  the  subjects  of  our  sketch  have  been  assuming  functions  in  advance 
of  fitness.  Many  of  these  essays  eventuate  seemingly  well  by  virtue  of  the  law  of  natural 
adaptability  and  tolerance  of  bad  conditions,  by  virtue  of  chauce  also  and  native  wit. 
Very  frequently  these  functions  are  bunglingly  performed,  and  hence  the  raw  material 
of  universal  discontent  and  of  cowardly  lamentations,  none  of  which  are  so  bitter  as 
those  compelled  by  needless  disease.  The  hope,  however,  is  still  indulged,  that  through 
the  vicissitudes  of  early  inexperience,  the  wisdom  of  middle  aud  later  years  may  be 
assured;  but  this  hope  proves  illusory,  and  as  the  sands  of  life  are  running  out,  men 
admit  that  they  have  just  begun  to  discover  what  could  have  been  of  the  utmost  use 
only  at  the  threshold  of  their  career. 

Conclusion. — Thus  the  exigencies  of  an  individual  life  emphasize  the  verdict  of 
| sociology  against  the  domination  of  a single  idea  or  class  over  other  equally  important 
ideas.  On  the  other  hand,  breadth  in  education  is  seen  to  receive  its  primary  justifica- 
tion, only  in  so  far  as  breadth  tends  primarily  to  place  a youth  promptly  in  command 
of  his  functions  as  they  arise — his  inevitable  functions  as  a complex  organism,  a worker, 
a neighbor,  a parent  and  a citizen. 

Such  a type  of  manhood,  based  upon  efficiency,  enhances  the  significance  of  certain 
recent  applications  of  modern  science  to  the  practical  problems  of  life  as  they  occur 
to-day;  enhances  the  value  of  every  effort  to  produce,  in  available  shape,  the  elements 
at  least  of  a science  of  health — domestic  and  public,  as  well  as  personal  ; the  elements 
of  rational  ethics  and  practical  charity;  the  elements  of  a popular  political  economy; 
the  elements,  in  fact,  of  all  those  intellectual  and  moral  needs  that  are  human  and 
universal,  in  contrast  to  those  that  conduce  merely  to  elegance. 

One  already  discerns  the  first  crude  recognitions  of  health  as  a rival  element,  thus 
far,  of  course,  marked  by  amusing  blindness  to  the  scope  of  subject.  High  schools  and 
private  academies  have  for  some  time  offered  an  isolated  and  often  optional  course  in 
personal  hygiene  as  a sacrifice  to  this  shrine.  Among  quite  recent  advances  it  must  be 
noted  that,  even  in  conservative  Connecticut,  since  my  indictment  of  the  modern 
system  for  sanitary  neglect  in  the  public  schools,  Yale  and  elsewhere  ( New  Englander, 
i March,  1885),  we  have  had  the  pleasure,  after  the  ebullition  of  some  ridicule,  of  seeing 
advertised  the  first  lectures  ou  pulic  health  that  the  ancient  Yale  Medical  Department 
has  ever  given;  while,  as  I speak,  the  teachers  of  the  elementary  schools  throughout 
Vol.  IV — 29 


450 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


the  State  are  industriously  cramming  up  the  new  State  text-hook  on  hygiene,  which  iu 
a few  days  they  must  introduce  to  children  as  young  as  the  ninth  year. 

The  name  and  pretence  of  hygiene,  however,  must  not  be  mistaken  for  the  spirit. 
High  schools  give  relatively  too  much  attention  to  anatomy  and  physiology,  too  little  to 
domestic  health,  and  absolutely  none  in  the  public  and  social  sense  of  the  term.  This  ’] 
instruction  also  comes  too  late,  as  the  great  majority  of  children  are  obliged  to  go  to 
work  before  even  their  elementary  schooling  is  finished. 

The  new  Connecticut  text-book  for  the  lower  grades,  where  the  real  work  of  the 
public  schools  is  done,  originated  ultimately,  like  many  of  its  predecessors,  as  a po-  - 
litical  expedient,  comes  before  the  public,  finally,  as  a sop  to  the  so-called  temperance 
faction,  not  as  an  unbiased  contribution  to  the  cause  of  true  sanitary  science. 

Nothing  but  disappointment,  however,  is  likely  to  follow  any  radical  treatment  of 
the  subject,  or  entire  reliance  on  any  text-book  and  a certain  number  of  quizzes  thereon,  q 
Certainly,  if  a text-book  covers  the  cardinal  points,  if  it  is  of  special  public  as  well  as  ; 
of  personal  interest,  if  it  enlarges  our  ideas  of  neighborliness  and  citizenship,  it  may 
well  be  considered  among  many  means.  But  it  should  not  stand  for  an  isolated  study, 
foreign  to,  and  unassimilated  with,  the  rest  of  the  public  system. 

The  Common  Branches. — I think  that  the  common  branches  alone  could  be  so  taught 
as  to  popularize  health  notions,  among  others — commercial,  economic,  patriotic,  etc. 
And  how  could  this  be  done?  By  discrimination  in  the  selection  of  subject  matter.  He 
who  selects  the  exercises  in  school  readers  or  the  problems  in  the  arithmetic,  he  who 
adapts  a geography,  or  who  compiles  a school  history,  determines,  in  a measure,  the 
trend  of  early  ideas,  the  range  of  vocabulary,  and  especially  the  early  conceptions  of 
the  applicability  of  knowledge. 

To  learn  to  read,  then,  might  mean  to  learn  to  appreciate  clear  and  useful  ideas,  as 
well  as  to  get  the  cue  for  graceful  intonation.  The  comparative  history  of  physical 
culture,  the  annals  of  sanitary  investigation,  striking  incidents  of  the  dependence  of 
success  or  bankruptcy  upon  personal  or  municipal  health  intelligence,  the  growing 
debility  and  decline  of  some  fiimilies  and  peoples,  and  the  increasing  vigor  of  others, 
the  pathology  of  crime,  the  physical  basis  of  poverty,  and  an  abundance  of  similar 
material  offer  as  interesting  a field  for  selection  as  can  be  found — oiler  as  useful  and 
elegant  a vocabulary,  as  wide  a scope  for  linguistic  analysis,  for  elocutionary  effect,  for 
collateral  observation  and  investigation,  and  as  fruitful  themes,  also,  for  the  practice  of 
composition. 

The  monotonous,  commercial  tones  of  our  arithmetics  might  easily  be  varied  by 
numerical  problems  in  air-space  allowance,  domestic  heating,  plumbing,  relative  cost 
of  foods,  comparative  mortality  rates,  and  so  on.  Occasional  paragraphs  in  geography 
exhibit  considerable  elasticity,  and  might  include,  for  instance,  the  telluric  and  pa- 
ludal origin  and  distribution  of  diseased  and  healthy  conditions,  as  well  as  the  source 
of  the  banana  and  tobacco  crops.  Drawing  exercises  could  also  be  varied  in  a similar 
manner.  A comparison  of  the  ways  in  which  people  now  live  and  formerly  lived,  with 
reference  to  the  healthful  tendencies  of  modern  life,  and  the  permanent  physiological 
results  of  many  eveuts,  would  constitute  a good  running  corollary  in  our  school 
histories. 

In  our  advanced  schools  the  practical  references  and  applications  of  physics  and 
chemistry  could  profitably  be  directed  to  the  phenomena  conspicuously  underlying 
sanitatiou — to  those  involved  in  the  hygiene  of  the  eye,  of  food,  especially  of  milk 
adulteration  and  preservation,  of  stoves,  furnaces,  steam-heating  systems  and  the 
various  methods  of  lighting,  to  the  phenomena  of  ground  air  and  water,  of  decomposi- 
tion and  of  purification — in  fact,  to  what  the  ordinary  householder  and  voter  should  j 
be  called  upon  to  deal  with.  The  cooking  lessons  which  are  being  introduced  into  the 
common  schools  are,  of  necessity,  largely  sauitary  in  effect. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  IIVGIENE. 


451 


In  this  way  the  teaching  of  the  common  branches  could  be  rendered  contributory  to, 
if  not,  indeed,  independent  of,  a special  course,  from  the  outset  familiarizing  the  young, 
if  not  with  advanced  knowledge  of  themselves,  at  least  with  the  facts  and  ideas  directly 
underlying  such  knowledge,  and  leadiug  gradually  up  to  it. 

Morally  considered,  such  a rendering  of  the  common  branches  would  be  suggestive 
and  excitant  of  the  altruistic  emotions,  and  would  be  apt  to  encourage  just  such  senti- 
ments as  are  needed  to  facilitate  dignified  dealings,  man  with  man.  The  spectacle  of 
disaster  from  want  of  forethought  primarily  awakens  interest  in  the  prudential  virtues. 

Sanitary  literature  is,  moreover,  largely  the  history  of  the  interdependence  of  man- 


kind as  brothers  and  safeguards  one  of  another.  Nowhere  does  the  primeval  question, 


“Am  I my  brother’s  keeper?  ” receive  a clearer  or  more  emphatic  answer  than  in  the 
story  of  the  reciprocal  precautions  required  by  social  life,  and  in  these  modern  applica- 
tions of  the  golden  rule. 

This  study  elevates  voluntary  right  doing  to  a higher  plane  of  urgency;  and  the 
fact  receives  the  strongest  possible  enforcement  that  voluntary  cooperation  can  never 
be  superseded  by  the  executive  machinery  of  the  law.  Throughout  society  there  is 
a low,  constantly-swelling  undertone  of  smothered  exasperation  engendered  by  the 
slowly  increasing  aggregate  of  petty  injustice,  petty  frauds  and  infringements,  delays 
and  grievous  compromises  that  are  practically  beyond  the  help  of  the  courts  or  of  pub- 
lic opinion  because  of  their  very  pettiness,  and  of  the  loss  of  dignity  and  the  net  pecu- 
niary loss  occasioned  by  invoking  the  aid  of  the  expensive  and  uncertain  public  machin- 
ery of  justice.  A disposition  to  do  w'hat  is  right  from  self-interest,  uncompelled  by  fear 
of  the  strong  arm  of  the  law,  requires  just  such  culture  as  sanitary  science  offers;  just 
such  a revelation  of  the  utter  defenselessuess  of  any  person  or  of  any  community 
against  the  heedlessness  and  ignorance  of  others. 

Continuation  Schools. — Another  promising  institution,  strong  while  yet  in  its  infancy, 
I invoke  to  aid  the  cause.  I refer  to  the  continuation  schools  or  enterprises  where  volun- 
tary and  often  isolated  effort  is  taking  form  for  the  purpose  of  obtaining  secondary  and 
higher  educational  advantages  for  an  interesting  class  whose  circumstances  thrust  the 
desired  education  out  of  reach,  or,  perchance,  whose  leisure  hours  would  preferably  have 
been  hours  of  senseless  waste  and  apathy  to  all  that  is  elevating  and  ennobling. 

For  this  class  there  would  otherwise  be  an  abrupt  transition  from  school  and  its 
forced  mental  activity  to  labor  and  a condition  of  mental  stagnation.  Here  the  fault 
evidently  lies  in  a too  sudden  withdrawal  of  every  inducement  to  read  and  to  think. 
These  enterprises  seek  to  hold  on  to  what  has  been  gained  in  the  common  school,  and 
then  to  supervise  the  critical  years  of  early  manhood  and  womanhood,  and  by  giving 
wholesome  and  attractive  occupation  to  the  mind,  free  from  petty  restraint,  to  lead  on 
to  more  permanent  habits  of  acquisition  and  self-reliance. 

Many  of  these  enterprises  are  characterized  by  a system  of  central  expert  guidance 
and  examination,  together  with  a prescribed  course  of  periodical  and  other  reading. 
“The  Chautauqua  Circle,”  “ The  Correspondence  University  of  Chicago,”  “The 
Meisterschaft  Language  System,”  and  others,  are  typical  of  such  projects,  as  the  lyceum 
is  of  an  older  and  more  local  expression  of  the  same  endeavor.  All  such  voluntary 
effort,  without  exception,  including  even  the  Sunday  school  and  evening  public  schools, 
present,  to  a greater  or  less  degree,  opportunities  for  sanitary  or  collateral  study.  In 
some  an  extended  special  course  would  be  convenient,  and  would  be  an  attractive  addi- 
tion to  the  advertised  curricula.  In  others  much  could  be  done  in  the  indirect  manner 
which  I have  suggested. 

Special  Text-hooks. — Before  dismissing  the  subject  of  an  elementary  text-book  for 
general  use,  it  should  be  noted  that  not  one  at  present  approaches  any  adequate  treat- 
ment of  sanitary  science.  The  production  of  such  a work,  however,  would  remove  the 
objections  of  many  who  think  we  cannot  dispense  with  a book.  It  should  be  element- 


452 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ary,  concise  and  comprehensive.  It  should  be  devoid  of  anatomical  and  physiological 
refinement.  Brevity  and  clearness  require  considerable  reliance  upon  truthful  and 
artistic  illustration.  The  book  should,  above  all,  be  such  as  would  keep  abreast  of  the 
age  of  the  pupil,  and  such  as  one  would  desire  to  preserve  and  refer  to  in  later  years. 

It  should  open  with  some  fundamental  biological  principles,  and  proceed  at  once  to 
dietetics  as  applied  to  age,  occupation  and  the  sick-room;  not  omitting  Flint’s  reassur- 
ances about  over-feeding,  nor  the  physiological  basis  of  the  sugar  instinct,  nor  yet  the 
frequent  necessity  of  overcoming  a repugnance  to  fat.  Intemperance  should  be  pre- 
sented among  numerous  correlated  evils  that  lie  deep  in  the  constitution  of  society.  Its 
causes  include  not  merely  the  opportunities  for  drunkenness,  but  also  many  unhy- 
gienic and  adverse  social  conditions,  such  as  discontent,  idleness,  unhealthy',  contentious 
or  cheerless  homes,  which  oftener  cause  drunkenness  than  result  from  them.  Insuffi- 
cient or  improper  diet,  hereditary  tendencies  to  excess  and  shiftlessness,  defective  edu- 
cation, etc.,  are  other  important  factors. 

Then  should  follow  the  care  of  the  brain  and  nervous  system,  of  the  eyes,  skin, 
teeth  and  emunctories,  the  hygiene  of  marriage  so  far  as  regards  age,  and  the  intensifi- 
cation of  hereditary  diseases. 

Then  the  hygiene  of  dwellings  and  of  occupation,  heating,  lighting,  ventilation  and 
drainage,  adhering  closely  to  the  few  principles  that  are  practically  beyond  cavil. 

The  final  chapters  should  be  devoted  to  public  sanitation  aud  the  duties  of  citizen- 
ship that  pertain  to  overcrowding,  water  supply,  sewerage,  surface  and  subsoil  pollu- 
tion, pollution  of  potable  waters,  communicable  diseases,  vaccination,  quarantine,  etc. 

Sexual  hygiene  is  of  primary  importance,  and  elementary  knowdedge  begins  to  be 
applicable  at  puberty,  that  is,  as  a rule,  near  the  end  of  the  common-school  course. 
But,  for  obvious  reasons,  I would  suggest  two  supplementary  chapters  meeting  the 
special  needs  of  the  sexes  respectively,  for  the  use  of  parents  in  the  proper  education  of 
their  children.  Long  before  the  States  could  be  induced  to  lay  aside  prudery  suffi- 
ciently to  attempt  the  control  of  inevitable  prostitution  in  the  interests  of  the  innocent 
victims  of  lust,  who  outnumber  the  sinners  a hundred  fold,  it  ought  to  be  feasible  to  at 
least  bring  the  sources  of  information  within  the  reach  of  young  men  before  it  is  too 
late.  I mean  at  the  age  when  the  arts  of  the  prostitute  are  most  alluring,  and  when 
seventy-five  per  cent,  of  these  willing  lads  are  about  to  follow  ignorantly  after  her, 
“ straightway  as  an  ox  goeth  to  the  slaughter.” 

Then  is  the  time,  if  ever,  to  enforce  the  fact  that  much  of  the  prevalent  disease  that 
goes  by  common  names  is  in  reality  the  concealed  and  direct  result  of  syphilis  ; to 
deny  the  tradition  that  gonorrhoea  is  but  an  inconvenient  streak  of  luck  ; and  to  show 
that  from  it  frequently  proceed  the  strictures  and  prostatic  diseases  of  later  years;  rheu- 
matic troubles  of  various  kinds,  and,  saddest  of  all,  much  of  the  uterine  aud  pelvic 
suffering  of  those  innocent  and  confiding  women  who  themselves  bring  to  the  altar  all 
purity  and  good  faith,  and  who,  alas!  can  learn  of  no  impediment. 

The  bearings  of  this  work  on  conduct  and  our  duty  as  men  and  citizens  should  be 
conspicuous  on  every  page,  and  this  should  be  its  strong  claim  to  public  recognition. 

The  advantage  of  a special  instructor  in  connection  with  or  independent  of  a text- 
book are  obvious.  In  the  public  schools  particularly  there  is  need  of  an  expert  physi- 
cian, as  in  the  Belgian  system,  to  act  as  a health  inspector  and  adviser,  as  well  as  gen- 
eral manager  of  health  instruction.  On  the  other  hand,  it  is  safe  to  assume  that  in 
elementary  schools,  whatever  children  generally  should  know  and  feel,  adult  teachers 
generally  ought  to  be  able  to  impart.  The  claim  is  measurably  true  that  “ the  normal 
school  lies  at  the  very  basis  of  national  safety  aud  prosperity  ;”  and  the  immaturity  of 
its  graduates  warrants  any  reasonable  occasion,  such  as  this,  for  further  delay  in  sending 
them  forth. 

Public  Libraries. — Closely  allied  to  the  work  of  the  continuation  schools  are  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


453 


public  libraries  scattered  throughout  the  land.  Here  is  a powerful  educational  instru- 
ment well  nigh  turned  over  to  mere  transient  amusement.  Strong  indeed  as  is  the 
passion  lor  trashy  hooks,  yet  the  people  should  have  a chance  to  read  good  ones.  It 
should  be  made  easy  for  people  to  brush  against  the  very  best.  Let  the  public  library 
elevate  the  public  taste,  not  the  popular  clamor  drag  down  the  management. 

Colleges. — A constant  adjustment  of  college  education  to  the  life  needs  of  its  recipi- 
ents has  been  tardily  going  on,  and  the  resultant  tendencies  are  marked  by  a liberality 
and  freedom  heretofore  undreamed  of.  The  inductive  sciences  have  come  into  promi- 
nence in  consequence  of  this  adjustment,  and  in  recent  years  biology  has  come  to  the 
front  as  one  of  the  best  expressions  of  the  principles  underlying,  not  only  life,  but  con- 
duct. Taught  as  the  classics  are  taught,  as  mere  book-lore,  these  sciences  have  indeed 
failed  of  the  whole  effect  that  was  expected  of  them— of  strengthening  the  faculties, 
of  promoting  keener  observation,  and  quicker  and  closer  adaptation  to  the  exigencies 
of  real  life.  Improved  methods  of  teaching  will  doubtless  enhance  the  net  gain  ; but 
we  are  doubly  gainers  by  every  advance  in  the  selection  of  sciences  which  not  only 
humanize  our  learning,  but  also  bring  its  data  more  nearly  withiu  our  actual  experi- 
ence. Dealing  with  the  guidance  of  personal  action  in  daily  and  practical  life,  and 
with  the  moral  and  political  bearings  of  conduct  and  a large  class  of  apparently  indif- 
ferent activities,  sanitary  science  deserves  to  rank  among  the  highest  kinds  of  learning 
which  society  must  utilize  to  its  own  integrity,  and  which  it  is  therefore  the  duty  of 
the  State  and  of  its  representative  institutions  to  encourage  and  enforce. 

In  the  sense  in  which  the  technical  sciences  are  special  studies,  sanitation  also  is 
destiued  to  become  a special  department  of  practice  as  soon  as  a demand  can  be  created 
for  expert  assistance.  But  elementary  and  widespread  intelligence  must  necessarily 
precede  this  demand,  and  lienee  college  work  lies  at  present  with  the  undergraduate 
departments.  At  first,  elementary  instruction  should  be  attempted  in  college  and 
common  schools  alike.  Later,  when  students  enter  with  some  preparation  in  this 
branch,  it  should  take  its  proper  place  among  the  other  advanced  courses  which  it  is 
the  province  of  a college  to  follow  into  their  higher  and  wider  applications. 

The  University. — Any  adequate  treatment  of  the  subject  from  the  university  stand- 
point would  include  : — 

1.  An  enthusiastic  specialist,  free  from  the  distractions  of  manifold  and  remote 
duties  and  interests. 

2.  A collection  of  typical  sanitary  appliances  and  materials  for  experiment,  which, 
with  excursions,  would  facilitate  a full  demonstration  of  the  principles  and  details. 

3.  A well-stocked  sanitary  library,  which,  in  America,  is  one  of  the  rarest 
advantages. 

This  outfit  could  not  only  form  the  nucleus  of  a special  department  for  all  who 
might  be  desirous  to  pursue  systematic  study  with  abundant  facilities,  but  its  relations 
with  the  professional  schools  should  be  intimate.  Here  the  medical  students,  pre- 
sumably familiar  with  the  personal  applications  of  physiology,  might  inquire  into  the 
technical  and  public  aspects  of  the  subject.  Doctors,  as  a rule,  are  lame  iu  the  details 
of  mechanical  appliances.  Both  they  and  the  public  generally  are  eternally  referred  to 
books  and  pamphlets,  when  they  need  to  examine  and  witness  the  action  of  appliances. 

Here  the  civil  engineers  might  readily  supplement  their  mathematical  and  mechan- 
ical training  with  setiological,  histological  and  other  studies  essential  to  an  intelligent 
treatment  of  many  municipal  engineering  problems. 

Architects,  ministers,  lawyers,  and  those  who  contemplate  divers  other  avocations 
would  be  sure  to  find  something  applicable  to  their  particular  needs,  for  the  element  of 
health  enters  into  trade  and  manufacture,  into  architecture  and  sermons,  pedagogy,  law 
cases  and  legislative  enactments. 

The  Press. — Passing  now  from  agencies  mainly  educational  to  those  which  must  ever 


454 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


be  potentially  so,  we  have  to  consider,  first,  the  wide  influence  of  a cheap  press,  osten- 
sibly devoted  to  spreading  the  news,  hut  in  reality  wielding  a mighty  authority  over 
the  masses,  to  whom  the  newspaper  comes  as  the  infallible  gospel  of  the  hour.  Selfish 
commercial  and  political  chicanery,  or  worse,  the  mere  whim  of  the  despot  who  occupies 
the  editorial  chair,  too  often  determines  the  nature  of  this  influence.  The  animus  is  not 
infrequently  obscure.  One  often  waits  for  weeks  and  months  before  the  announcement 
of  a commercial  or  political  move,  or  perchance  an  accidental  circumstance  reveals  the 
policy  at  the  bottom  of  some  bland  news  item  or  editorial  professedly  in  behalf  of  the 
beloved  people. 

These  editors  please  themselves  as  to  what  the  public  shall  or  shall  not  know.  They 
will  get  a community  all  torn  up  over  any  and  every  scheme  that  suits  their  ideas,  and 
they  will  also  garble,  abbreviate,  ignore  or  cold-pack  any  contribution  or  utterance,  on 
the  slightest  provocation. 

This  thraldom  to  partisan  or  to  petty  motives  extends  even  to  the  selected  miscellany. 
Not  long  since,  when  an  associated  press  applied  for  the  admission  of  their  reporter 
to  the  sessions  of  the  “Connecticut  Academy  of  Arts  and  Sciences,”  the  storm 
of  spontaneous  opposition  that  instantly  overwhelmed  the  proposal  left  a sad  after- 
thought concerning  the  diffusion  of  knowledge.  It  was  shown,  however,  that  the  only 
interest  the  applicants  had  in  scientific  discussions  was  to  get  copy,  to  reduce  science  to 
bombast,  and  to  make  sport  or  spurious  erudition  for  their  patrons. 

But  when  the  worst  has  been  said  of  journalism,  we  must  ever  return  to  it  with 
forbearance  and  with  hope,  as  to  one  of  the  grandest  instrumentalities  for  popular  enlight- 
enment. When  the  press  emulates  the  standard  set  by  its  better  representatives,  public 
health  stands  ready  to  purify  its  columns.  I do  not  mean  that  the  mortality  tables  of 
the  rural  districts,  or  the  ordinary  reports  of  the  doings  of  health  boards  could  be  of  any 
use  to  the  general  reader.  But  once  let  a paper  undertake  to  really  boom  local  sanitary 
problems,  or  to  ventilate  the  question  in  a general  way,  and  the  public  would  soon  get 
a liberal  education,  with  class  day  and  diploma  thrown  in.  It  has  been  truly  observed 
that  “the  damnable  iteration  day  after  day  of  earnest  conviction  wears  like  the  dropping 
of  water  upon  the  stone.”  Once  discard  the  legends  of  miraculous  cures,  mon- 
strosities, snake  and  lizard  ejections,  and  so  on,  and  substitute  therefor  the  wonders  of 
science  which  really  exist,  and  the  press  would  soon  have  an  inquiry  and  contribution 
department  that  would  be  a credit  to  the  intelligence  of  journalism  and  of  its  patrons. 

Boards  of  Health.— Some  nicely  gotten  up  annual  reports  of  State  Health  Boards  are 
regularly  circulated  among  the  physicians  and  influential  tax  payers  of  our  communi- 
ties, for  obvious  reasons,  but  their  contents,  meagre  though  they  be,  seldom  reach  beyond 
the  select  few.  Now,  iu  view  of  the  hampered  conditiou  of  these  public  benefactors, 
bound  hand  and  foot  by  limited  and  uncertain  jurisdiction,  it  would  seem  rational,  in 
accordance  with  a well  known  law  of  moral  dynamics,  that  this  pent-up  wisdom  should 
frequently  find  vent  in  the  public  prints,  in  the  shape  of  matured  discussion  and 
valuable  contributions  to  the  general  stock  of  information. 

The  Pulpit. — Theoretically,  it  is  urged  with  great  vehemence  in  certain  quarters,  that 
there  is  an  irreconcilable  antagonism  between  the  doctrine  of  a divine  special  providence 
as  it  is  generally  conceived  of,  and  the  opposite  doctrine  or  induction  of  an  established 
order  never  interfered  with.  The  Bible  itself  seems  to  be  hopelessly  contradictory  on 
this  point,  although  evidencing  a preponderance  of  belief  in  a divinity  frequently 
repenting  his  own  established  plan  and  varying  it  for  the  purpose  of  occasional  revenge, 
chastisement,  or  reward.  Practically,  however,  ministers  of  wide  and  unexceptionable 
reputation  unhesitatingly  assure  me  that  they  could  easily  reconcile  these  discrepancies, 
and  could  conscientiously  teach  that  physiological  law  is  part  of  God’s  law — that  for  a 
person  to  endanger  his  own  or  another’s  health,  or  for  a community  to  do  likewise,  is  a 
sin  against  God.  Nevertheless,  one  frankly  confessed  the  difficulty  with  such  teaching 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  455 


to  be,  that  where  there  is  one  member  of  a congregation  iutell  igent  enough  to  understand 
the  operation  of  secondary  causes,  nineteen  would  construe  his  sermon  as  a profane 
limitation  of  the  God-like  prerogatives.  He  admitted  that  about  once  a year  he  him- 
self preached  a sermon  directing  attention  to  the  origin  of  much  sickness,  distress  and 
consequent  irritability  and  wickedness,  in  ignorance  of  and  disobedience  to  physiological 
law,  but  he  afways^felt  obliged  to  intersperse  some  evidence  of  the  fatherly  interference, 
for  the  benefit  of  His  favored  ones  and  for  the  glory  of  His  name. 

At  the  death-bed,  and  when  the  harm  is  done  beyond  repair,  what  alternative, 
indeed,  is  there,  but  the  lesson  of  patience  and  readiness  for  the  inevitable  fate  that 
awaits  us  all?  In  his  contact  with  the  bereaved  and  the  ruined,  it  would  afford  vain 
comfort  for  the  dominie  to  insist  on  the  lesson  of  disobedience,  even  if,  indeed,  the 
lesson  were  tolerated.  But  in  the  pulpit  the  personal  element  disappears;  atall  events, 
when  the  scourge  is  rife  in  distant  places,  or  when  the  preacher  can  take  a text  nearer 
home  without  directly  exasperating  any  of  his  parishioners,  he  need  lose  no  opportu- 
nity to  brand  the  avarice  or  the  stupidity  that  precipitates  public  distress  or  private 
wreckage  as  he  believes  it  should  be  branded,  a crime — a case  where  sanitary  science 
overlaps  the  province  of  morals  and  extends  the  significance  of  both. 

What  the  confessional  is  capable  of  as  an  educator  may  readily  be  inferred  from  the 
extreme  latitude  of  the  topics  dealt  with.  Devout  Catholic  women,  whose  physicians 
have  enjoined  separation  a thoro  for  therapeutic  reasons,  have  frequently  admitted  that 
the  measure  has  been  nullified  by  their  confessors,  who  teach  that  it  were  far  better  to 
die  from  rapid  child-bearing  and  exhaustion  or  to  remain  invalids,  than  to  thus  endanger 
the  integrity  of  their  marriage  contract. 

Periodicals. — For  persons  of  scholarly  and  scientific  tastes,  there  is  a generous  peri- 
odic literature,  which  constitutes  an  arena  wherein  all  sorts  of  questions  of  general 
import  may  be  discussed;  au  instrument  for  advancing  and  spreading  information  on 
any  of  the  interesting  topics  of  the  hour  or  of  the  age.  As  a rule,  this  literature  is 
relatively  poor  in  sanitary  contributions  as  compared  with  others  of  an  instructive 
nature.  During  the  years  1884,  1885  and  1886,  the  following  periodicals  published  a 
variable  number  of  articles  chiefly  sanitary  in  tone  : Harper's , G;  The  Century , 6; 

The  North  American  Review,  9;  The  Atlantic , 0;  The  Popular  Science  Monthly , 51  long 
and  55  short;  LittelVs  Living  Age , 4;  The  Contemporary  Review , 5;  The  Nineteenth  Cen- 
tury, 11.  The  figures  alone  suggest  a very  important  work  to  be  done  here  by  reaching 
the  few  whose  culture  finally  affects  the  many. 

The  Novelist. — But  it  is  to  the  creator  of  the  really  popular  literature  of  the  day — to 
the  novelist,  that  the  inspiration  should  come  to  rightly  educate  as  well  as  to  amuse. 
That  light  reading  is  an  educator,  far-reaching  and  powerful,  is  nowhere  denied,  but  its 
uncoordinated  and  deleterious  influence  has  provoked  against  it  a hostility  that  is  not 
sufficiently  outspoken.  Dazed  with  the  excitement  of  this  ephemeral  and  overwrought 
world  of  romance,  the  attention  of  its  slavish  devotees  is  observed  to  return  only  slug- 
gishly to  the  prosaic  realities  of  life,  and  then  frequently  with  au  impaired  power  of 
self-control.  Many  bad  features,  however,  could  easily  be  overlooked,  if  the  good 
elements  were  at  all  conspicuous,  if  there  resulted  on  the  whole  higher  ideals  and  more 
accurate  information,  but  until  discriminate  indulgence  is  reduced  to  a fine  art,  or  until 
the  need  for  it  becomes  less  urgent,  discontent  and  indifference  to  duty  will  continue  to 
be  the  principal  lasting  effects. 

Novelists,  as  a rule,  are  fair  students  of  the  bearing  of  medical  science  on  their  trade. 
When  it  is  necessary  to  rid  a story  of  characters  at  j ust  the  right  time — when  the 
flower  must  fade,  or  the  fiend  must  dangle — or  when  provision  must  be  made  for  the 
customary  ante-mortem  revelations,  repentances,  and  codicils,  the  conscientious  novelist 
is  rarely  at  a loss  for  symptomatology  and  tolerable  therapeutics  also. 


456 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Now,  is  there  no  place  for  prophylaxis  in  romance,  to  vary  the  tedious  ruin  and 
rescue  that  now  overtakes  everybody  ? 

Is  nobody  shrewd  enough  to  study  and  champion  a cause  which  was  grand  enough 
to  enlist  the  pen  of  Charles  Kingsley  ? 

Such  an  author  might  be  assured  of  an  ever  fruitful  source  of  inspiration  and  sug- 
gestion of  novel,  startling,  pathetic  and  pleasing  situations.  In  his  excursions  among 
the  people  for  materials,  he  would  look  upon  humanity  from  a unique  standpoint,  as 
advantageous  as  many  another  favorite  one.  With  no  forced  nor  far-fetched  effort  on 
his  part,  his  stories,  or  some  of  them,  in  his  own  characteristic  style,  would  indicate  a 
deeper  insight  into  human  nature,  and  into  the  romantic,  tragic,  and  even  comical 
situations  growing  out  of  the  operation  of  nature’s  inexorable  laws. 

If  faithfully  pursued,  these  studies  would  furnish  yet  another  evidence  of  conscious 
social  worth,  aside  from  the  author’s  money  valuation  of  himself.  He  would  find  the 
new  ideas  shading  into  and  completing  other  social,  moral  or  political  phases  of  his 
book,  and  the  latter  would,  in  consequence,  approach  a perfection,  and  win  a corres- 
ponding appreciation  not  otherwise  attainable. 

I have  striven  to  show  that  the  burden  of  popular  enlightenment  is  distributed; 
that  no  one  of  its  many  agencies  has  a monopoly,  and  that  the  sanitary  function  of  our 
educational  resources  is  not  sufficiently  emphasized.  Above  all,  I hope  I have  shown 
that  the  prospect  of  general  intelligence  in  this,  that  is  so  vital  to  efficient  manhood  and 
social  stability,  is  not  solely  dependent  on  any  book  or  any  specialty,  but  is  founded  on 
the  possibility  of  making  some  aspect  of  the  problem  an  integral  part  of  many  of  the 
living  issues  of  the  time;  and  finally,  on  the  possibility  of  attaining  the  desired  com- 
pass, symmetry,  and  moderation  during  the  pre-adult  age  of  education. 


DISCUSSION. 

Dr.  Yates,  Oldham,  England,  congratulated  the  essayist  on  the  value  of  his 
paper  and  the  breadth  of  his  ideas,  and  stated  that  the  subject  was  of  primal 
importance  to  the  people  of  all  countries,  old  or  new.  It  was  essential  that  all  proper 
education  should  begin  as  early  as  possible.  Education,  whether  good  or  bad,  com- 
menced with  the  first  hour  and  only  terminated  with  death.  Proper  training  and 
the  teaching  of  sanitary  truths  should  not  be  delayed  till  adolescence  and  adult  age, 
but  should  begin  ab  initio  and  continue  through  life.  Hitherto  hygiene  has  been 
very  much  neglected  as  a specific  branch  of  education.  Nevertheless,  in  our  own 
countiy  the  Ten  Hours’  Bill,  and  more  recently  the  Public  Health  Act,  may  be  cited 
as  evidence  of  the  progress  of  public  opinion  in  the  direction  of  sanitary  reform. 
The  operation  of  those  acts  has  been  most  beneficial,  both  in  the  prevention  of  prac- 
tices formerly  prejudicial  to  the  public  health,  and  in  the  compulsory  enforcement 
of  provisions  designed  to  abate  or  remove  insanitary  conditions.  Nevertheless  the 
progress  of  sanitary  education  is  slow,  for  the  supineness  and  ignorance  of  the  many 
and  the  active  hostility  of  the  self-interested  few  have  for  long  ages  offered  an  almost 
invincible  barrier  against  progress.  He  concluded  by  congratulating  the  sanitary 
reformers  of  the  United  States  on  their  intelligent  labors,  and  wished  them  signal 
success  in  their  work. 

Dr.  It.  C.  Davis,  of  Seneca,  S.  C. , in  discussing  the  paper  of  Dr.  Leighton,  said: 
The  subject  is  a vast  one.  It  is  truly  of  first  importance.  Sanitary  education  is 
fearfully  neglected,  especially  in  the  southern  portion  of  the  United  States.  Our 
schools  and  colleges  seldom  teach  it.  Our  young  men  and  women  have  their  minds 
taught  while  the  body  is  greatly  neglected.  Hundreds  of  our  youth  are  ruined  and 
disabled  for  life  by  lack  of  proper  care  and  sanitary  instruction  while  attending  schools 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


457 


and  colleges.  Then  this  subject  must  always  be  before  our  minds.  Our  every  effort 
should  be  made  to  have  sanitary  education  taught  in  every  school  and  college. 

Dr.  Schenck,  of  Kansas,  said  : It  is  gratifying  to  those  of  us  who  are  growing  gray 
in  the  profession  to  find  our  young  men  giving  us  as  interesting  papers  as  the  one 
just  read,  upon  the  grandest,  noblest  theme  in  medicine — the  prevention  of  disease 
and  the  most  perfect  attainable  development  of  the  physical,  intellectual  and  moral 
forces  in  man.  Those  of  us  who  have  labored  in  this  field  know  full  well  its  diffi- 
culties in  America.  Across  the  water  it  may  be  different.  Here  all  power  emanates 
from  the  people.  The  legislator  is  elected  by  the  people  upon  some  issue  foreign  to 
State  medicine  ; but  he  no  sooner  receives  the  franchises  of  the  people  than,  like 
Minerva,  he  springs  from  the  brain  of  Jupiter  fully  fledged.  Utterly  ignorant  an 
hour  before,  he  now  knows  all  about  State  medicine,  and  is  restive  under  any  inti- 
mation to  the  contrary.  Public  and  international  hygiene  must  be  taught  in  our 
schools,  thoroughly  taught ; the  people  must  be  educated,  and  the  legislator  informed 
on  this  subject  before  he  becomes  a legislator. 

In  Kansas  we  require  hygiene  and  the  action  of  alcoholics  to  be  taught  in  every 
department  of  the  public  schools — but,  alas ! how  little  do  the  teachers  know;  and 
have  we  not  “ heathen  nearer  home  ” ? How  little  do  the  doctors  know  ; how  little 
interest  they  feel,  is  manifest  by  the  barely  two  score  present  in  this  Section  out  of 
the  2500  present  at  this  Congress. 

Let  us  labor,  and  labor  earnestly,  to  awaken  an  interest  in  the  profession  in  pre- 
ventive medicine  commensurate  with  its  importance. 

A.  Hazlewood,  Grand  Rapids,  Mich. , considers  the  subject  of  supreme  import- 
ance. The  difficulties  are  many,  in  carrying  out  the  teachings  of  the  essayist.  The 
difficulties  have  been  somewhat  described  by  the  last  speaker.  The  teachers  in  our 
public  schools  are  yet  unable,  from  lack  of  knowledge,  to  carry  out  the  law  which 
directs  that  sanitary  laws  shall  be  taught  in  all  schools.  Our  school  boards  are,  as  a 
rule,  yet  uneducated  in  the  science  of  sanitation,  even  in  its  simpler  axioms.  Recog- 
nizing these  difficulties,  the  State  Board  of  Health  of  Michigan  have  inaugurated 
and  maintained  for  some  years  a plan  of  holding  sanitary  conventions  at  intervals  of 
a few  months,  at  different  points  in  the  State,  where  essays  are  read  and  discussions 
held  upon  subjects  more  or  less  local,  viz. : the  water  supply  and  sewerage  of  the 
town  where  the  convention  is  held,  and  other  subjects  of  personal  hygiene,  food 
preparation  and  adulteration  are  discussed. 

It  is  to  be  hoped  that  this  subject  will  be  well  discussed,  and  some  practicable 
measures  be  suggested,  which  will  enable  us  to  have  the  children  educated  in  such  a 
manner  as  to  develop  a sound  mind  in  a sound  body,  and  thus  enhance  the  well-being 
of  society. 

Dr.  George  Troup  Maxwell,  of  Florida,  made  extended  remarks,  advocating 
the  necessity  of  physical  training  in  education,  and  a methodical  system  of  regular 
intermissions  during  the  daily  periods  of  study,  and  detailed  his  experience  in  refer- 
ence to  systems  of  education  during  his  term  of  service  in  the  school  board  of  the 
State  of  Delaware. 


458 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


A PRACTICAL  AND  ' COMMON-SENSE  VIEW  OF  PUBLIC  AND 
INTERNATIONAL  HYGIENE;  THE  IMPORTANCE  OF  THE  WORK; 
WHAT  IS  PRACTICABLE;  THE  NECESSITY  OF  HARMONY  AND 
UNIFORMITY  OF  ACTION  AMONG  THE  STATES  OF  THE 
REPUBLIC,  IN  ORDER  TO  MAKE  EFFECTIVE  THE  WORK  OF 
THE  INTERNATIONAL  MEDICAL  CONGRESS  TO  PREVENT 
DISEASES  AND  EPIDEMICS. 

UNE  YUE  PRATIQUE  ET  SENSEE  D’HYGIENE  PUBLIQUE  INTERNATIONALE, 
L’IMPORTANCE  DU  TRAVAIL;  CE  QUI  EST  PRATICABLE;  LA  NECESSITE  BE 
L’HARMONIE  ET  DE  L'UNIFORMITE  D’ACTION  PARMI  LES  ETATS  DE  LA 
REPUBLIQUE  AFIN  DE  RENDRE  EFFICACES  LES  EFFORTS  DU  CONGRES 
MEDICAL  INTERNATIONAL  POUR  PREVENIR  LES  MALADIES  ET  LES  EPI- 
DEMIES. 

EINE  PRAKTISCHE  UND  VERNUNFTIGE  ANSICHT  UBER  OFFENTLICHE  UND  INTERNA- 
TIONALE HYGIENE;  DIE  WICHTIGKEIT  DES  WERKES;  WAS  THUNLICII ; DIE  NOTH- 
WENDIGKEIT  HARMONISCHER  UND  GLEICHFORMIGER  HANDLUNG  UN  TER  DEN 
STAATEN  DER  REPUBLIK,  UM  DAS  WERK  DES  INTERNATIONALEN  MEDICINISCHEN 
CONGRESSES  ZUR  VERHUTUNG  VON  KRANKHEITEN  UND  EPIDEMIEEN  WIRKSAM  ZU 
MACHEN. 

BY  URIEL  R.  MILNER,  M.D., 

Of  New  Orleans,  La. 


JEsculapius  was  worshiped  by  the  ancient  Greeks  “as  the  god  of  medicine  and  the 
patron  of  physicians,”  and  in  the  Homeric  poems  he  is  styled  the  “blameless  physi- 
cian,” whose  sons  were  serving  in  the  Greek  arm}7  before  Troy.  In  the  temples  of 
Rome  the  JEsclepiadse,  or  children  of  this  famous  god,  held  an  hereditary  priesthood, 
and  were  the  only  regular  physicians;  but  in  the  course  of  time  they  took  pupils,  and 
initiated  them  into  the  mysteries  of  medicine. 

Hygeia  was  the  virgin  goddess  of  health  and  daughter  of  JEsculapius,  whose  flowing 
garments  and  smiling  face,  feeding  a serpent  from  a cup — emblematic  of  divine  wisdom 
and  beneficence — fitly  represents  the  divine  wisdom  of  hygienic  scientists  of  to-day. 

But  it  is  different  to-day  from  then.  Now,  when  pestilence  sweeps  over  our 
land,  bearing  in  its  dark  embrace  the  pointed  shaft  of  death  to  the  sacred  shrines  and 
hearts  of  thousands  who  were,  but  a day  before,  prosperous  and  happy,  or  when  epi- 
demics suddenly  spring  forth  in  great  cities,  stretching  out  their  dark  wings  and  hover- 
ing, like  a funeral  pall,  over  the  inhabitants,  we  call  not  for  the  sacred  serpents  of 
“Epidaurus,”  to  appease  the  wrath  of  the  gods  and  heal  the  sick,  but  we  send  for  the 
best  disinfectants,  the  best  physicians  and  well-trained  nurses. 

The  thing  is  upon  us — it  is  too  late  now  ! All  that  we  can  do  is  to  save,  as  far  as 
we  can,  human  life.  The  pestilence  is  raging;  we  cannot  check  the  storm ; we  may 
prevent  accretions  to  its  death-loving  maw — rising  from  the  sick  room  and  from  ordure 
and  from  cesspools — by  cleanliness  and  disinfectants,  and  sweeping  the  banquettes,  and 
flushing  continuously  the  gutters  and  streets  with  pure  water,  to  stop  the  exhalations 
of  that  poisonous  effluvia  which  was,  perhaps,  the  main  cause  of  th.e  pestilence. 

But  when  the  raging  storm  is  upon  us  it  is  too  late  to  attend  to  those  long-neglected 
sanitary  matters  which,  if  they  had  been  attended  to,  would  have  prevented  the  pesti- 
lence— such  as  grading  and  draining  the  city,  instead  of  having  foul  slush  pools  and 
stagnating  ditches,  falsely  called  sewers  ; and  such  as  compelling  every  property  owner 
to  have  his  property  surrounded  by  stone  or  brick  banquettes,  instead  of  decaying  and 
rotting  plank,  etc.  It  is  in  the  time  of  health  and  prosperity  that  cities  should  fortify 
themselves  against  the  encroachments  of  disease  and  pestilence. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


459 


This  exordium  brings  me  to  the  consideration  of  the  importance  of  Public  Hygiene, 
which  we  shall  view  in  two  aspects:  First’y,  local;  secondly,  public. 

By  local  hygiene  I mean  its  application  as  a scientific  art  to  all  inhabited  localities, 
whether  in  the  rural  districts,  villages  and  incorporated  towns  of  the  country,  or  in  the 

[great  cities  of  trade  and  commerce. 

The  importance  of  understanding  hygienic  science  as  to  the  behavior  of  effluvium 
will  be  illustrated  by  the  following  example  : — 

About  forty  years  ago  I knew  a plauter  whose  plantation  lay  on  the  Cahawba  river, 
Alabama.  He  had  lived  for  many  years  upon  the  eastern  bank  of  the  river,  and  his 
residence  aud  plautation  houses  were  built  upon  ground  sufficiently  high  above  the 
bottom  lands  to  give  him  good  natural  drainage.  Here  his  family  were  healthy  and  he 
was  prosperous.  He  owned  a beautiful  building  site  on  elevated  ground  on  the  west 
side  of  the  river,  where  he  built  himself  a palatial  residence  replete  with  all  the  con- 
veniences of  modern  life,  and  surrounded  by  every  attraction  that  wealth  aud  cultivated 
taste  could  procure.  To  this  new  home  he  brought  his  family,  full  of  bright  hopes  of 
enjoying  life  in  full  view  of  his  fertile  fields  across  the  river.  But  how  sad  the  sequel. 
Soon  the  whole  family,  one  after  another,  were  stricken  with  malarial  fever,  and  they 
were  finally  compelled  to  abandon  the  place.  What  was  the  matter?  In  their  plain 
plantation  home  on  the  east  side  of  the  river,  right  in  the  jaws  of  the  river  bottom, 
they  were  scarcely  ever  sick  ; but  here  they  were  continuously  sick.  The  reason 
is  this  : In  their  plain  plantation  home  the  vapors  and  exhalations  from  the  paludal 

soil,  under  the  influence  of  the  morning  sun,  were  carried  above  their  heads  and  wafted 
on  ; but  in  their  elevated  palatial  residence  on  the  west  bank,  it  hovered  over  and 
setttled  upon  them. 

Now  it  is  doubtful  whether  there  are  any  hygienists  who  would  have  condemned 
this  site  before  the  experiment  had  been  made;  but,  having  been  made,  the  fact  becomes 
a unit  and  a factor  in  scientific  hygiene  and  sanitary  work,  and  is  therefore  valuable. 
It  shows  the  importance  of  not  only  inspecting  the  surroundings  of  proposed  sites  for 
private  and  public  buildings  with  the  eye,  but  the  necessity  of  analyzing  the  atmo- 
sphere to  determine  what  effluvium  may  pollute  it,  and  to  learn  its  character,  nature 
and  source,  and  whether  or  not  it  can  be  certainly  destroyed.  And  it  also  points  to 
the  necessity  of  having  well-educated,  scientific  hygienists  who  may  be  consulted  and 
employed  for  this  purpose.  Local  hygienic  science  should  be  applied  to  the  proper 
location  and  construction  of  buildings  in  the  country,  and  to  the  drainage  of  farms  and 
plantations.  And  when  public  hygiene,  to  which  I shall  soon  specially  call  youratten- 
tion,  shall  have  gained  that  hold  upon  the  popular  feeling  and  heart  of  the  country 
which  it  is  destined  to  attain,  there  shall  scarcely  be  found  a habitation  in  the  country 
where  health  shall  not  bloom  perennially. 

The  towns  and  villages  of  our  rural  districts  are  scarcely  ever  visited  by  pestilence  or 
epidemics,  because  they  have  good  pure  water  from  springs  or  wells,  healthy  atmo- 
sphere to  breathe,  not  being  contaminated  with  an  excess  of  carbonic  acid,  as  is  the 
casein  crowded  tenement  houses  ; aud  they  are  comparatively  isolated  from  contagious 
and  infectious  poisons  because  these  prefer  the  big  cities  along  our  sea  coasts  and  the 
banks  of  our  great  rivers.  Let  these  villages  and  towns  keep  clean,  avoid  excremen- 
titious  accumulations,  and  the  fouling  of  springs  and  wells,  attend  to  their  surround- 
ings by  ditching,  draining,  and  bringing  into  cultivation  all  of  their  paludal  lands, 
aud  they  need  never  be  sick  unless  they  are  indiscreet  in  food  or  clothing.  There  is  an 
old  adage  that  says  “ there  is  no  rule  without  an  exception.”  To  this  I demur.  Truth 
has  no  exception.  From  a clearly  demonstrated  problem  there  is  no  escape.  The 
absolute  laws  of  nature  are  immutable,  whether  as  observed  in  the  harmonious  revolu- 
tions of  mighty  suns  and  systems,  or  in  the  evolution  of  a protoplasmic  germ  cell  into  a 
man  or  into  an  elephant.  Therefore,  rule,  if  it  means  a fact  or  a law,  has  no  exception. 


4G0 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


If  rural  communities  would  perfectly  obey  the  laws  of  hygiene,  particularly  by 
providing  agaiust  local  causes  of  disease,  they  would  certainly  enjoy  an  immunity  from 
epidemics  ; but  only  in  this  way  can  they  be  exempted  from  the  danger  of  epidemical 
visitations  ; and  by  the  experience  of  the  past  they  should  take  timely  warning.  We 
shall  point  the  above  admonition  by  the  following  examples  : In  the  year  1851,  an 
epidemic  of  typhoid  fever  raged  with  virulent  and  destructive  effect  throughout  middle 
Georgia,  scourging  all  the  plantations  of  my  section,  and  did  not  stop  its  ravages 
there,  but  from  South  Carolina  to  Texas  it  swept  the  country.  This  epidemic  of  typhoid 
fever  did  not  die  out  for  three  years.  About  this  time  the  disease  became  gradually 
sporadic.  In  those  days  local  sanitary  measures  were  almost  wholly  neglected  on  the 
plantations.  The  quarters  of  the  negroes  were  filthy,  and  they  were  often  crowded 
with  their  families  into  very  small  huts.  There  was  one  ruling  idea  among  the  mas- 
ters and  planters  of  that  day,  “ to  make  more  cotton,  to  buy  more  negroes  to  make 
more  cotton.”  This  idea  seems  to  have  excluded  everything  like  a well-ordered  system 
of  sanitary  regulations,  which  should  have  formed  a part  of  their  moral  and  religious 
code  for  the  government  and  protection  of  the  health  and  lives  of  their  slaves. 

The  matter  of  astonishment  is  that  the  rural  districts  in  those  days  were  not  more 
frequently  scourged  with  virulent  diseases.  There  can  be  no  doubt  that  this  epidemic 
sprang  from  local  filth,  whatever  the  germ  may  be,  aud  might  have  been  prevented  by 
wise  and  timely  local  sanitary  and  hygienic  means.  In  this  connection  I take  pleasure 
in  referring  to  the  graduation  thesis,  “ The  Spontaneous  Origin  of  Diphtheria  and 
Typhoid  Fever,”  by  J.  M.  Wellwood,  m.d.,  Tulane  University  of  Louisiana,  Medical 
Department,  1887,  published  in  the  New  Orleans  Medical  and  Surgical  Journal , August 
number.  Dr.  Wellwood  gives  a graphic  account  of  an  outbreak  of  typhoid  fever  in  the 
town  of  Minnedosa,  on  the  little  Saskatchewan  river,  Canada,  in  the  spring  of  1881, 
caused  by  rotting  potatoes  in  a cellar  which  had  been  flooded  by  an  overflow  of  the 
river;  and  of  au  outbreak  of  diphtheria  in  the  same  locality  in  the  autumn  of  1882, 
caused  by  “ using  water  from  a shallow  well  supplied  with  surface  water,  and  in  the 
direct  line  of  drainage  from  the  stables;”  and  another  of  diphtheria  in  the  winter  of 
1884-5.  The  Doctor  says:  “The  water  supply  was  good,  but  the  family  was  large  and 
crowded  together  in  a poorly-ventilated,  hot  room,  which  was  used  for  every  purpose; 
and  what  was  worse  than  all,  they  had  a large  barrel  of  pig  feed,  which  they  kept  near 
the  stove  to  prevent  its  freezing;  into  this  they  were  in  the  habit  of  pouring  dish  wash- 
ings, sour  milk,  aud  other  refuse  matter  mixed  with  bran.  This  was  found  in  a state 
of  fermentation,  and  was,  doubtless,  the  cause  of  the  trouble.”  Hundreds  of  instances 
like  these  could  be  collected  in  this  and  all  other  countries,  proving  the  indigenous 
origin  of  most  of  our  contagious  aud  infectious  diseases,  aud  that  the  best  means  of 
preventing  them  is  the  execution  of  a wise  and  vigorous  system  of  local  sanitary  laws. 

Everybody  has  a right  to  healthy  atmosphere  and  good  water,  and  it  is  an  offense 
against  the  common  rights  of  man,  by  individuals  or  by  communities,  for  them  to  live  in 
such  a manner  as  to  pollute  either  the  air  they  breathe  or  the  water  that  they  or  others 
drink.  Our  exotic  diseases  are  very  few  indeed,  and  if  strong  laws  were  enacted  and 
executed,  compelling  local  cleanliness  in  the  rural  districts,  towns  and  cities  of  the 
States,  exotic  diseases  would  never  take  root.  Now,  what  is  needful  for  preventing 
diseases  and  securing  health  and  prosperity  for  our  rural  districts,  villages  and  towns, 
is  still  more  urgently  demanded  for  our  great  emporiums. 

And  I shall  offer  the  following  rule  for  forming  a pretty  clever  idea  of  the  sanitary 
condition  of  any  city:  The  differences  in  topographical  and  climatic  conditions  of  the 
great  cities  of  the  world  aud  the  influence  which  these  exert  upon  the  healths  aud  lives 
of  a people  being  known,  the  percentage  of  deaths  in  any  city  will  enable  us  to  deter- 
mine approximately  how  clean  it  is.  Everything  should  be  kept  clean  in  great  cities; 
the  banquettes  should  be  made  of  stone  or  brick,  and  daily  swept;  drainage  should  be 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  461 


made  perfect,  and  the  sewers  should  never  be  allowed  to  contain  stagnating  water;  the 
streets  should  he  paved  with  enduring  substances;  all  houses  should  be  built  upon  dry 
and  elevated  ground,  and  perfect  drainage  from  them  into  the  sewers  should  be  made 
imperative.  Damp  and  wet  cellars  and  crowded  tenement  houses  should  be  equally 
forbidden.  The  water  lor  drinking  purposes  should  be  pure;  and  there  should  he  an 
abundant  supply  for  flushing  the  streets.  Tiiere  should  be  no  foul  cesspits  allowed 
within  a city’s  limits;  and  the  refuse  from  kitchens,  stables  and  markets  should  be 
removed  daily  and  consumed  in  such  manner  as  to  prevent  foul  effluvia.  All  of  these 
things  should  be  enforced  by  the  strong  arm  of  the  law  and  backed  by  the  money  of 
the  people,  and  then  we  shall  have  an  atmosphere  so  pure  and  invigorating,  and  a 
population  so  vigorous,  healthy  and  happy  that  they  would  enjoy  perfect  immunity 
from  all  infectious  diseases.  And  will  it  pay?  That  is  the  all-absorbing  question  of 
this  railroad  age  as  to  any  business  or  enterprise.  Will  it  pay  ? 

I know  of  no  city  in  the  United  States  where  hygienic  science  has  been  utilized  to 
the  perfecting  of  sanitary  work;  but  Chicago,  haviug  the  lowest  death-rate  of  any  city 
in  this  country,  and  considering  the  fact  that  she  is,  perhaps,  the  largest  meat-packing 
centre  and  fruit  mart  of  the  West,  we  logically  conclude  that  she  has  the  best  sanitary 
regulations  of  all,  and  is  the  cleanest  of  all.  I mean  no  reflection  upon  this  great  and 
beautiful  city,  nor  upon  Philadelphia,  nor  upon  any  other  city,  but  we  must  adhere  to 
our  ride.  While  Chicago  has  yet  much  to  do  in  a sanitary  regard,  what  she  has  done 
has  certainly  paid.  Now,  Mr.  President,  as  to  our  city  of  New  Orleans. 

The  great  problem  now  before  our  people  is  that  of  drainage.  The  difficulty  is  to 
get  a sufficient  fall  for  our  sewers  and  canals,  from  the  river  to  the  lakes. 

Several  of  our  eminent  engineers  have  offered  plans  showing  that  the  perfect  drain- 
age of  New  Orleans  is  practicable,  that  it  can  be  accomplished,  but  that  it  will  require 
a tremendous  outlay  of  money,  and  the  city  is  financially  embarrassed.  Thus,  we  are 
left  sitting  upon  the  ragged  edge  of  uncertain  hope  and  desire,  exposed  as  much  now  to 
an  outbreak  of  yellow  fever  epidemics  as  we  have  been  for  the  last  sixty  years.  If  yel- 
low fever,  with  us,  was  an  exotic  due  to  importation,  then  it  should  never  have  raged 
in  our  midst,  because  our  quarantine  laws  have  been  rigidly  enforced  from  the  days  of 
Governor  Robertson,  more  than  sixty  years  ago,  down  to  the  present  time.  The  Gov- 
ernor became  so  despondent  as  to  say,  in  his  message  of  1822:  “The  State  resorted  to 
quarantine  under  the  expectation  that  it  would  add  to  the  chances  of  escape  from  this 
dreadful  visitation.  If  this  hope  be  fallacious,  if  no  good  effect  has  been  produced, 
if  even  a procrastination  of  its  appearance  lias  not  resulted  from  the  measure,  then  it 
should  be  abandoned  and  our  commerce  relieved  from  the  expense  and  inconvenience 
which  it  occasions.”  But  the  fact  is,  yellow  fever  is  a home  product,  it  is  indigenous 
with  us,  which  fact  is  proven  from  the  records  of  its  history,  from  the  first  epidemic  in 
New  Orleans,  1796,  to  the  last  one  in  1878. 

Dr.  Thomas  (Essai  sur  la  Fifcvre  Jaune,  p.  70),  says  that  the  epidemic  of  1796  was 
caused  by  the  exposure  to  the  solar  heat  of  a large  extent  of  marshy  land  in  the  work 
of  ditching  and  fortifications  ordered  by  the  Spanish  Baron  Carondelet,  then  Governor 
of  Louisiana. 

The  great  naturalist,  Humboldt,  held  that  yellow  fever  is  indigenous  in  the  countries 
where  it  prevails;  but  it  is  not  my  purpose  to  argue  this  question  in  this  place.  I have 
only  alluded  to  it  in  its  bearing  upon  local  hygiene,  especially  in  the  city  of  New 
Orleans.  I affirm  that  our  only  chance  to  escape  epidemics  is  to  remove  the  cause,  no 
matter  what  the  work  may  cost;  and  it  is  perfectly  practicable  and  will  pay  better  than 
any  other  investment  to  which  capital  can  be  applied  in  our  city.  Indeed,  if  it  were 
for  no  other  object  than  for  comfort,  the  city  that  does  not  give  its  inhabitants  good 
banquettes,  good  streets,  drainage,  pure  water  and  a healthy  atmosphere,  belongs  rather 
to  a barbaric  age  than  to  the  present  progressive  civilization. 


462 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


We  now  pass  to  the  consideration  of  Public  Hygiene  in  a more  general  sense.  By 
public  hygiene,  I mean  not  only  the  central  gearing  of  the  machinery  of  sanitary  order 
and  health,  represented  by  the  State  Boards  of  Health,  the  American  Sanitary  Associa- 
tion and  their  auxiliary  bodies,  etc.,  hut  also  the  application  of  this  science  as  an 
important  elementary  branch  of  common  and  public  school  education,  from  which  those 
who  would  become  teachers  may  ascend  to  collegiate  classes  in  our  universities  and 
medical  colleges. 

The  order  of  nature  and  the  harmonious  rhythm  of  the  universe  teach  us  the  neces- 
sity of  order  and  harmony  in  all  public  work.  Many  of  the  State  Boards  of  Health  have 
disagreed  in  matters  concerning  the  public  health,  and  every  disagreement  of  this  kind 
injures  the  public  confidence  and  retards  the  work  which  these  hoards  are  legally  con- 
stituted to  perform,  and  for  which  this  International  Medical  Congress,  embodying  the 
wisdom  of  the  most  learned  and  advanced  thinkers  and  scientists  of  the  civilized 
world,  has  assembled  at  this  great  Capital  to-day. 

It  may  be  that  the  local  sanitary  work  of  these  hoards  may  not  be  much  interfered 
with  by  little  jarrings  among  themselves,  but  there  is  a grander  aim,  far-reaching  in  its 
scope,  embracing  not  only  single  States  but  all  of  the  States,  and  that  is  to  infuse  into 
the  minds  of  the  people  an  intelligent  comprehension  of  the  real  value  of  public 
hygiene  to  the  whole  country.  Hence,  it  is  of  the  first  importance  to  have  the  funda- 
mental principles  and  doctrines  of  public  hygiene  defined,  and  to  become  the  guide 
book,  the  constitution  and  laws,  so  to  speak,  of  the  boards  of  health  of  all  the  States. 
In  this  way  there  would  be  a concert  of  action  in  every  important  measure.  The 
medical  associations  of  States  and  societies  of  cities  and  counties  would  act  in  concert 
with  the  boards  of  health  upon  recognized  fundamental  principles  of  hygienic  science, 
and  a power  would  be  accorded  to  the  medical  profession  which  would  be  acknowledged 
in  all  of  the  State  legislative  assemblies  and  in  the  national  councils  of  the  country. 
Our  profession  would,  indeed,  rise  to  the  dignity  and  importance  of  being  the  guardian 
of  the  public  health.  It  would  be  recognized  as  a power  in  the  government  whose 
counsels  should  be  heeded.  Its  well-advised  measures  for  public  sanitary  work 
would  receive  such  State  and  National  aid  as  would  make  it  a success,  and  sanitary 
improvements  would  finally  master  all  preventable  diseases.  But,  again,  this  recog- 
nized merit  and  value  of  our  profession  by  the  people  at  large  would  awaken  an  inter- 
est among  all  intelligent  people  in  hygienic  science  and  lay  the  foundation  for  a new 
era  in  the  education  of  the  children  and  youth  of  the  land. 

And  when  hygiene  in  its  elementary  branches  shall  he  taught  in  our  public  schools, 
professorships  for  this  science  will  he  demanded  in  every  university  and  medical  col- 
lege of  the  country.  To  build  the  temple  of  public  hygiene  to  its  grandest  propor- 
tions and  greatest  usefulness,  we  must  lay  its  foundation  in  the  hearts  of  the  mothers 
of  the  country  and  at  the  threshold  and  sacred  shrine  of  infancy.  The  mothers  must  be 
taught  not  to  nurse  their  babies  too  often  nor  too  much,  and  thus  raise  them  up  to  observe 
hygienic  laws,  and  they  will  unconsciously  imbibe  from  their  mothers’  bosoms  their 
first  and  most  lasting  lessons  in  hygienic  science.  It  is  an  appalling  fact  that  at  least 
twenty-five  per  cent,  of  the  deaths  of  children  up  to  two  and  a half  years  old  are 
caused  by  over-feeding.  Their  stomachs  become  so  continuously  distended  with  milk 
from  the  bosom  or  bottle,  or  from  both,  that  the  muscular  fibres  become  paralyzed,  and 
the  physiological  function  of  contraction,  motion  and  secretion  ceases  altogether,  and 
there  is  scarcely  any  absorption  of  nutriment.  The  stomachs  of  such  children  swing 
in  the  abdominal  cavity  like  blown-up  toy  bladders,  having  their  walls  so  thinned  that 
digestion  is  simply  impossible. 

Of  course  they  have  colics,  and  when  they  cry,  the  more  they  are  fed  the  faster 
they  are  starved.  Thus,  we  have  cholera  infantum,  inanition,  marasmus  and  all  of  the 
ailments  of  infancy.  They  are  starved  to  death  with  too  much  food  ! Here,  then,  we 





SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


463 


have  a field  for  public  hygiene  which  encompasses  the  human  family,  and,  as  a part  of 
our  philanthropic  work,  it  appeals,  with  touching  pathos,  to  our  profession  throughout 
the  world.  This  International  Medical  Congress  should  send  greeting  aud  wise  counsels 
to  all  the  laborers  in  this  field.  It  is  an  evil  which  has  its  source  in  ignorance  of 
hygienic  science,  aud  can  be  overcome.  The  family  physician  can  do  more  than  any- 
body else,  and  the  doctor  should  be  not  only  the  guardian,  but  the  mother  of  the 
children. 

And  if  there  should  be  a concert  of  action  among  physicians  to  instruct  their  clients 
in  the  matter  of  feeding  infants,  preventive  medicine  will  soon  have  raised  a monument 
for  itself,  even  in  this  one  work,  more  enduring  than  brass.  Lithe,  bright,  beautiful, 
healthy  children  will  gladden  the  home  circles  and  sweeten  the  very  air  with  their 
happy  songs,  spontaneously  arising  from  the  fountains  of  health. 

At  this  time,  however,  go  wherever  you  will,  you  will  meet  with  pale-faced,  stub- 
born, feeble,  fretful  dyspeptics  among  the  girls  and  boys,  whose  stomachs  were  so 
injured  in  infancy  as  to  create  morbid  appetites  which  they  cannot  govern,  and  which 
have  entailed  upon  them  the  miseries  of  confirmed  dyspeptics.  These  depraved,  dis- 
eased appetites  lead  them  into  all  sorts  of  bad  habits,  and  thousands  of  them  become 
criminals  or  fill  drunkards’  graves.  They  become  the  wards  of  the  government,  in 
the  asylums,  poor  houses  and  penitentiaries,  and  entail  upon  the  country  an  enormous 
expense.  Hence  it  would  pay  every  State  richly,  in  a material  way,  to  have  hygiene 
introduced  into  every  public  school  and  made  a branch  of  common  education.  But  in 
its  moral  aspect  it  is  of  greater  importance.  The  State  would  raise  up  a strong  and 
vigorous  manhood  aud  womanhood,  imbued  with  the  principles  of  self-government, 
and  on  this  foundation  the  intellectual  and  moral  faculties  would  grow  and  strengthen 
with  the  rolling  years.  Every  succeeding  generation  would  be  stronger,  more  intellec- 
tual, and  purer  in  moral  sentiment  and  life  than  the  preceding.  The  percentage  of 
pauperism,  of  crime,  and  of  drunkenness  and  other  immoral  practices,  would  daily 
diminish.  The  physical,  intellectual  and  moral  health  of  the  parents  would  be  trans- 
mitted to  their  children.  Children  would  be  boru  good,  and  the  acme  of  a perfect  civ- 
ilization might  be  ultimately  reached.  A generation  of  statesmen  and  rulers  formed 
of  such  material  as  this,  would  give  a momentum  to  intellectual,  moral  and  material 
progress  which  would  lift  the  depraved  and  ignorant  out  of  the  slums  of  beastliness, 
and  make  them  good  and  profitable  citizens.  The  pillars  of  society,  resting  upon  such 
shoulders,  would  be  as  firm  as  the  everlasting  granite. 

I now  pass  to  the  consideration  of  the  third  division  of  my  subject,  International 
Hygiene.  By  international  hygiene  I mean  those  sanitary  regulations  at  the  empo- 
riums, upon  the  great  thoroughfares  of  commerce  between  the  nations  of  the  earth, 
which  will  prevent  the  carrying  of  contagious  and  infectious  diseases,  preserve  the 
healths  of  the  traveling  and  emigrating  masses,  so  that  at  no  time  will  either  travel  or 
trade  be  much  obstructed. 

In  years  past,  so  far  as  we  have  been  concerned  down  South,  quarantine  was  a system 
of  public  oppression.  At  every  cry  of  yellow  fever  in  any  of  the  South  American  cities, 
on  the  Mexican  gulf,  or  in  the  West  India  isles,  or  at  any  place  along  the  borders  of  the 
Atlantic,  or  in  a neighboring  State,  the  boards  of  health  of  all  the  States  were  author- 
ized, and  did  at  once  institute,  the  most  rigid  quarantine  regulations,  preventing  ships 
and  steamers  from  landing  their  cargoes,  and  compelling  them,  with  all  on  board  of 
their  vessels,  to  be  retained  for  fifteen  or  twenty  days,  or  even  longer,  at  the  quarantine 
stations  to  which  they  may  have  been  ordered.  Thus,  the  traveling  public  suffered  the 
anguish  of  imprisonment  for  a long  time,  not  to  speak  of  their  loss  of  time  and  money 
and  absence  from  their  families  and  the  benefits  of  pure  country  air,  of  which  they 
were  deprived.  The  fact  is,  that  yellow  fever  is  indigenous  where  it  prevails,  and  local 
sanitary  work  is  the  only  remedy  against  its  outbreaks.  Its  period  of  incubation  is  not 


464 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


certainly  known,  and  it  is  cruel  to  keep  well  people  at  quarantine,  to  see  whether  they 
are  going  to  be  sick. 

The  uncharitableness  of  charging  everything  bad  upon  our  neighbors  is  graphically 
alluded  to  by  the  great  naturalist,  philosopher,  and  historian,  Alexander  Humboldt. 

He  says : “ In  all  climates  men  appear  to  find  some  consolation  in  the  idea  that  a 
disease  considered  pestilential  is  of  foreign  origin.  As  malignant  fevers  easily  originate 
in  a numerous  crew  cooped  in  dirty  vessels,  the  beginning  of  an  epidemic  may  be  fre- 
quently traced  to  the  period  of  the  arrival  of  a squadron,  and  when,  instead  of  attribu- 
ting the  disease  to  vitiated  air  contained  in  the  vessel  deprived  of  ventilation,  or  to  the 
effects  of  an  ardent  and  unhealthy  climate  on  sailors  newly  landed,  they  affirm  that  it 
was  imported  from  a neighboring  port  where  a squadron  or  convoy  touched  during  its 
navigation  from  Europe  to  America.” 

And  I must  here  be  permitted,  in  vindication  of  the  truth  of  its  indigenous  origin  in 
every  place  where  it  has  prevailed,  to  refer  in  chronological  order  to  the  dates  and  places 
of  its  prevalence  and  to  the  authorities  sustaining  this  view,  from  the  year  1699  to  the 
year  1878,  which  was  collated  by  Dr.  J.  C.  Le  Hardy,  of  Savannah,  Georgia,  and  made 
available  in  my  pamphlet  on  “ Quarantine  and  the  Indigenous  Nature  of  Yellow  Fever,” 
published  in  the  year  1880.  Dr.  Le  Hardy  commences  with  La  Roche’s  great  work  on 
yellow  fever,  and  shows  the  domestic  origin  of  yellow  fever  in  the  city  of  Philadelphia 
in  the  year  1699,  1793-’7-’8-’9,  and  in  1805-’19-’20,  and  in  1853.  And  of  all  of  the 
epidemics  of  this  long  time  in  New  York,  Boston,  Baltimore,  Pensacola,  etc. 

Dr.  Drake,  in  the  ‘ ‘ Topography  and  Diseases  of  the  Valley  of  the  Mississippi,”  gives 
full  evidences  of  the  local  origin  of  the  disease  in  New  Orleans  from  1791  to  1843, 
inclusive. 

Deveze  gives  the  same  opinion  (“  Traits  de  la  Ftovre  Jaune,”  Paris,  1820,  page  311). 
Condie,  Folwell  and  Potter  confirm  this  view.  1798,  New  London,  Holt  says  it  was  of 
local  origin.  The  Medical  Repository , page  217,  Richmond,  records  that  its  outbreak  in 
the  penitentiary  of  Virginia,  1806,  was  of  local  origin. 

The  same  cause  for  this  dread  disease  is  confirmed  as  follows  : — 

By  Campbell,  1817,  Charleston,  S.  C. 

By  Watts,  1819,  Mobile,  Ala. 

By  Merrill,  of  New  Orleans,  Bay  St.  Louis,  1820. 

By  Dr.  Daniell,  1817,  1820,  Savannah. 

By  Dr.  Waring,  in  Report  to  City  Council,  1820,  Savannah. 

By  Dr.  Hill,  Medical  Recorder,  1821,  Wilmington. 

By  Strobel,  1821,  St.  Augustine. 

By  the  Memphis  Medical  Journal,  1823,  Natchez,  Mis3. 

By  Dr.  Hort,  ‘‘New  York  Quarantine  Reports,”  1825,  Florida. 

1826,  Apalachicola,  “ N.  Y.  Quarantine  Reports.” 

1837-’39-’43,  Mobile,  by  Dr.  Nott,  N.  O.  Journal  of  Medicine. 

1838,  Charleston,  by  Gaillard. 

1839,  St.  Augustine,  by  Monette. 

1840,  Augusta,  by  Uriel  R.  Milner,  N.  O. 

1842-’49-’52,  Charleston,  by  Simmons. 

1853,  New  Orleans,  by  Dr.  Hort,  “ New  York,  on  Quarantine.” 

1853-’4-’5,  New  Orleans,  by  E.  H.  Barton,  “ Report  of  Sanitary  Commission.” 

1853,  Houston,  Texas,  by  Ashbel  Smith. 

1854,  Charleston,  by  Dr.  W.  Wragg. 

1854,  Philadelphia,  by  La  Roche. 

1854,  Charleston,  by  “Mayor’s  Report,”  Dr.  McKall. 

1856,  Essay  on  “ Bilious  and  Yellow  Fever,”  page  9,  by  Dr.  Arnold. 

1854,  Ossabaw  Island,  by  Dr.  Warren. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  465 

1856,  Philadelphia,  “Six  sporadic  cases  from  domestic  causes,”  by  Dr.  Jewell. 

1858,  Savannah,  hy  J.  J.  Harris. 

1859,  New  Orleans,  “Incontestably  of  local  origin,”  by  A.  E.  Axson,  Official 
Report. 

1860,  New  Orleans,  “Sporadic  cases,”  by  C.  Delery,  Annual  Report  Board  of  Health. 

1863-4,  NewOrleans  : “Yellow  fever,  the  most  dreaded  scourge  of  New  Orleans,  was 

unequivocally  generated  in  a large  number  (25)  of  filthy  and  unventilated  gunboats 
and  other  naval  vessels  lying  idly  at  anchor  within  a mile  of  the  densest  portion  of  the 
city.”  E.  Harris’  Report. 

1864,  Savannah,  by  Dr.  Le  Hardy. 

1866,  “Its  cause  could  not  be  traced  outside  of  the  city,”  by  S.  A.  Smith.  New 
Orleans,  Report  of  Board  of  Health. 

1868-69,  New  Orleans  : “ Three  deaths  each  year.  Thedisease  originated  at  home.” 
Report  of  Board  of  Health. 

1870,  New  Orleans.  “No  direct  connection  with  foreign  importation  was  estab- 
lished.” Prof.  Joseph  Jones’s  Lectures,  1879. 

1871,  Charleston  (212  deaths).  “The  origin  of  the  disease  could  not  be  traced  to 
foreign  importation. ” Robert  Libby.  Report,  H.  O. 

1875,  New  Orleans  (100  cases).  “Started  in  the  Second  District.  No  trace  of 
importation.”  Annual  Report  of  Board  of  Health , 1876. 

1876,  New  Orleans  (74  cases).  “Careful  examination  by  the  President  of  the  Board 
of  Health,  by  the  sanitary  officers,  and  by  myself,  failed  to  discover  in  the  first  case  the 
slightest  clue  to  foreign  infection  from  any  ship,  person,  or  material.  This  applies  with 
equal  force  to  the  following  series  of  cases.”  Dr.  Joseph  Holt,  Sanitary  Inspector,  etc., 
and  now  President  of  our  State  Board  of  Health. 

1876,  Savannah,  by  J.  C.  Le  Hardy  : “From  local  causes.” 

Now,  if  this  view  of  the  origin  of  yellow  fever  be  certainly  established,  and  it  becomes 
the  doctrine  of  our  medical  colleges  as  a recognized  principle  of  hygienic  science,  quar- 
antine will  at  once  take  its  proper  place  and  value  in  public  and  international  hygiene. 
It  will  not  be  abolished,  because  it  is  an  indispensable  sanitary  institution  connected 
with,  and  an  important  factor  of  the  machinery  and  laws  for  preserving,  the  public 
health,  but  subordinate  to  local  sanitary  work  and  improvements. 

The  public  mind  will  be  withdrawn  from  it  as  a preventive  of  yellow  fever  and 
other  diseases,  and  the  energies  of  the  people  will  be  devoted  to  local  cleanliness.  The 
preventive  work  will  be  done  mainly  at  home,  while  quarantine  will  take  care  of  all 
infected  vessels,  receive  the  sick  into  the  hospitals,  disinfect  the  vessels,  crews  and 
passengers,  and  send  them  on  their  way  rejoicing. 

Then  there  will  be  very  little  delay  to  the  traveling  public  and  very  little  detention 
and  loss  to  commerce.  And  the  stimulus  thus  given  to  the  local  branches  of  public 
hygiene  will  ultimately  result  in  the  eradication  of  all  infectious  diseases,  and  prevent 
epidemics  everywhere.  We  shall  then  not  be  afraid  to  receive  individuals  fresh  from 
the  quarantine  stations,  knowing  that  in  a pure  atmosphere,  with  pure  water,  no  infec- 
tious diseases  can  become  epidemic  or  even  dangerous. 


Vol.  IV— 30 


466 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


EPIDEMIOLOGICAL  NOTES  ON  DENGUE  DURING  THE  AUTUMN 
OF  ] 883,  IN  BEYROUT,  SYRIA. 

OBSERVATIONS  EPIDEMIOLOGIQUES  SUR  LA  GIRAFFE  (DENGUE)  PENDANT 
L’AUTOMNE  DE  1883,  A BEYROUT,  SYRIE. 

EPIDEMIOLOGISCHE  NOTIZEN  UBER  DENGUE  W AHREND  DES  HERBSTES  1883  IN 

BEYROUT,  SYRIEN. 

BY  JOHN  WORTABET,  M.  D. , 

Of  Cairo,  Egypt. 

In  August,  1883,  it  was  reported  from  a town  on  the  northern  coast  of  Syria,  Lata- 
kia,  that  they  had  an  epidemic  of  dengue  fever,  which  soon  became  so  universal  that 
very  few  escaped  it.  How  it  came  there,  or  whether  it  originated  on  the  spot  from  some 
local  causes,  seems  to  be  unknown.  From  the  fact  that  it  was  not  heard  of  before  in 
any  other  place  which  would  account  for  its  importation,  it  seems  that  we  must  take 
the  latter  view,  and  believe  that  it  arose  there  de  novo,  from  some  “climatic  state  ” or 
“atmospheric  change,”  which  the  ancient  physicians  attributed  either  to  telluric 
exhalations,  or  to  some  intrinsic  change  in  the  water  held  by  the  atmosphere  itself, 
a change  which  is  caused  by  some  unusual  condition  of  the  season,  and  which  they 
called  by  the  general  name  of  “the  constitution  of  the  seasons.”  Having  once  origi- 
nated, it  seemed  to  spread  to  neighboring  places  by  importation,  as  the  sequel  will 
show. 

It  appeared  in  Beyrout  about  the  beginning  of  September,  and  in  two  or  three 
weeks  spread  through  the  whole  town.  In  October  it  had  become  so  universal  that 
very  few  escaped  it.  During  the  summer  many — probably  not  less  than  one-third  of 
the  inhabitants  of  Beyrout — had  gone  up  to  the  villages  of  the  Lebanon,  either  for  change 
of  air  or  for  the  cooler  atmosphere,  or  from  fear  of  an  outbreak  of  cholera  in  the  plains. 
As  they  returned  in  October  most  of  them  took  the  dengue. 

In  the  beginning  of  November  we  had  a heavy  storm  of  rain  with  much  lightning 
and  thunder,  which  continued  two  days  and  which  did  not  appear  to  have  any  sensible 
effect  on  the  epidemic — the  disease  still  picking  up  persons  who  had  previously  escaped. 
On  the  20th  of  the  same  month  there  was  another  heavy  fall  of  rain,  which  continued 
for  some  days,  but  notwithstanding  this  there  were  fresh  occurrences  of  the  fever  lin- 
gering through  the  whole  month  of  December. 

From  Beyrout  the  epidemic  was  propagated  to  all  the  neighboring  villages  at  the 
base  of  the  Lebanon,  where  it  spread  very  much  among  the  inhabitants;  but  it  did  not 
go  up  to  any  place  higher  than  2000  feet  above  the  level  of  the  sea,  except  in  the  case 
of  persons  who  took  it  with  them,  but  from  whom  it  was  not  communicated  to  others. 
Like  cholera,  it  seems  to  find  no  favorable  soil  for  its  extension  in  the  high  and  dry  air 
of  the  mountains.  It  spread  also  northward  as  far  as  Batrun  (the  ancient  Botrys,  a 
small  town  on  the  coast  between  Beyrout  and  Tripoli),  and  southward  to  Sidon,  from 
which  place  it  spread  also  to  the  low  villages  on  the  adjacent  hills.  In  Sidon  the  dis- 
ease was  so  widely  diffused  at  one  time  that,  when  a death  occurred  in  the  town,  the 
burial  could  be  attended  to  only  with  much  difficulty.  I have  no  certain  information 
as  to  how  far  south  the  epidemic  went,  but  I believe  it  reached  Tyre  and  Acre. 

The  former  visitations  of  dengue,  as  far  as  they  have  been  noticed  in  Syria  and 
neighboring  parts  of  the  East,  and  as  for  as  I have  been  able  to  find  out,  are  as  follows: 
It  appeared  in  Syria  for  the  first  time  in  1861,  when  it  seems  to  have  been  as  universal 
in  Beyrout  as  it  was  in  1883.  It  again  made  its  appearance  in  1865,  after  the  cholera, 
and  again  in  1867,  and  continued  to  reappear  in  the  early  autumn  of  1868,  ’69  and  ’70. 
It  is  reported  to  have  visited  Cairo  in  1779,  1801,  1S35,  and  in  1845.  Since  then  there 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  467 


Lave  been  slight  epidemics  of  it  at  Cairo,  in  1853  and  in  1868.  There  were  cases  of  it 
in  Cairo  in  1871,  and  it  raged  at  Port  Said  in  September  and  October  of  the  same  year. 
It  was  prevalent  at  Ismailieh  in  November,  1877,  where  it  has  continued' to  make  its 
appearance  every  autumn  since.  Cairo  and  other  parts  of  the  Delta  were  affected  by 
it.in  1880,  beginning  in  July  and  increasing  in  intensity  about  the  beginning  of  Octo- 
ber, when  humidity  is  at  its  height  in  lower  Egypt.  I am  not  aware  that  it  has  ever 
appeared  in  the  highly  dry  atmosphere  of  upper  Egypt — a fact  which,  taken  with 
others,  would  confirm  the  view  that  moisture  in  the  air  is  a favorable,  if  not  an  essen- 
tial condition  for  the  propagation  of  dengue  fever.  An  epidemic  of  what  now  appears 
to  have  been  evidently  dengue  fever  prevailed  over  all  Malta  and  Gozo  in  the  autumn 
of  1878.  The  mode  of  invasion,  the  symptoms  of  the  disease,  its  short  duration,  the 
eruption,  and  the  subsequent  debility,  mentioned  in  the  printed  Report  of  a commission 
of  medical  men  to  the  Governor,  leave  hardly  any  doubt  as  to  the  nature  of  the  epi- 
demic. By  a strange  oversight  it  . was  not  then  recognized.  It  was  probably  brought 
from  India  with  some  ship,  though  the  medical  commission  did  not  believe  that  it  was 
contagious,  and  supposed  that  it  owed  its  origin  “ to  local  conditions  or  to  a pandemic 
wave.”  A heavy  fall  of  rain  in  the  first  part  of  September,  followed  by  a protracted 
and  excessive  heat  and  moisture,  and  the  prevalence  of  sirocco,  they  thought,  materially 
contributed  to  the  diffusion  of  the  disease. 

The  epidemic  in  Beyrout  was  almost  absolutely  universal.  All  the  physicians  of  the 
town,  with  a single  exception,  had  it — myself  sharing  the  general  fate.  The  premonitory 
symptoms,  when  the  disease  was  not  ushered  in  suddenly,  were  general  lassitude  and 
a falling  off  of  the  appetite  for  two  or  three  days.  The  actual  invasion  usually  began 
with  a chill  and  fever,  severe  pains  in  the  limbs,  chiefly  in  the  back  and  knees,  frequent 
and  full  pulse,  sleeplessness,  and  a coated  tongue,  with  a very  bad  taste  in  the  mouth. 
This  continued  generally  for  three  or  four  days,  when  a red  eruption  appeared  on  the 
whole  body,  sometimes  involving  the  face.  On  the  appearance  of  the  eruption  the 
fever  generally  subsided,  and  the  patient  was  considered  convalescent,  though  there  was 
often  a slight  rise  of  the  temperature  about  the  sixth  day,  which  was  generally  unno- 
ticed. The  convalescence  was  usually  accompanied  by  much  weakness,  and  this  was 
protracted  for  some  weeks  in  elderly  or  debilitated  subjects.  In  a few  instances  there 
was  a real  relapse  of  most  of  the  symptoms  of  the  first  invasion,  though  in  a milder 
degree,  and  probably  without  the  eruption. 

In  looking  a little  more  closely  to  the  main  symptoms  of  the  disease  we  have  the  fol- 
lowing observations  to  make:  1.  The  articular  pain  which  has  given  this  fever  its  spe- 
cial name — Dengue , a Spanish  translation  of  the  word  dandy,  by  which  it  was  called 
among  the  negroes  of  the  West  Indies,  both  words  signifying  a stiff  gait  in  walking;  in 
Syria  it  early  received  the  name  of  “ Knee-fever,”  and  in  America  it  was  called  “Break- 
hone  fever.  ” All  these  names  point  to  the  pain,  which  affects  chiefly  the  knees  and  lum- 
bar portion  of  the  spinal  column,  and  which  is  quite  characteristic  of  this  disease.  I 
have  never  seen  any  swelling  of  the  joints,  though  they  are  said  to  he  sometimes  swol- 
len and  hot.  Pain  in  the  head  was  very  frequent,  especially  during  the  first  day  of  the 
fever,  and  often  accompanied  by  severe  pain  in  rolling  the  eyeballs  upward,  or  on  press- 
ing them  with  the  fingers.  2.  The  fever  generally  continued  from  three  to  five  days. 
.Sometimes  it  and  the  other  symptoms  were  so  mild  that  the  patient  did  not  keep  his 
bed;  but  occasionally  it  exceeded  the  fifth  day;  then  the  case  was  severer  than  usual.  I 
had  the  temperature  taken  carefully  in  six  cases  in  the  hospital,  morning  and  night,  and 
it  varied  between  37.5°  C.  (99.5°  F.)  and  40.2°  C.  (104.5°  F.) ; generally,  however,  a little 
higher  in  the  forenoon  than  in  the  afternoon.  It  is  said  that  in  the  dengue  fever  of 
India,  after  the  subsidence  of  the  fever,  about  the  third  or  fourth  day,  there  is  generally 
another  rise  of  the  temperature  about  the  sixth  day,  but  this  appears  to  have  been  rarely 
so  in  the  Syrian  epidemic.  In  only  one  of  the  hospital  cases  did  I observe  this  rise — 


468 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


private  patients  could  not  be  watched  so  easily,  as  they  left  their  beds  or  houses  as  soon 
as  they  felt  better,  and  considered  the  ailment  as  too  trivial  and  short  to  need  much 
attention.  3.  The  eruption  comes  out  over  the  whole  body  generally  about  the  third 
or  fourth  day.  In  some  cases  it  did  not  appear  at  all,  in  others  it  was  the  chief  symp- 
tom in  recognizing  the  disease.  When  it  came  out  well  it  was  generally  supposed  lo 
indicate  the  complete  subsidence  of  the  disease,  and  the  same  critical  relation  of  the 
eruption  to  the  fever  has  been  always  held  by  the  common  people  as  true  in  the  other 
exanthemata;  but  while  this  seems  to  be  true  in  most  cases,  it  is  not  so  in  every 
instance.  The  eruption  was  not  of  one  kind.  It  was  generally  papillary,  like  that  of 
measles,  slightly  raised  above  the  skin;  sometimes  it  had  a mottled  appearance  without 
any  elevation,  and  occasionally  there  was  an  erythematous  blush,  like  that  of  scarla- 
tina. In  every  case  the  color  was  more  or  less  red.  It  was  often  attended  hy  a 
pricking  sensation,  and  ended  by  desquamation.  The  general  constancy  of  the  erup- 
tion and  its  appearance  at  a certain  stage  of  the  fever,  followed  by  a decline  of  the 
symptoms,  clearly  point  to  the  classification  of  dengue  among  the  exanthematous 
fevers.  4.  The  digestive  f unctions  were  almost  invariably  impaired  to  a very  unusual 
degree.  The  appetite  was  completely  lost,  an  extremely  bad  taste  was  felt  in  the 
mouth,  and  the  bowels  were  always  constipated.  In  a few  cases  there  was  much 
irritability  of  the  alimentary  canal  with  some  vomiting  and  diarrhoea,  which  has  led  a 
few  medical  men  to  suppose  that  there  are  two  varieties  of  dengue,  called  by  them  the 
rheumatic  or  gastric;  but  this  is  evidently  a mistake,  for  the  gastro-intestinal  symp- 
toms were  accidental,  and  were  probably  owing  to  a previous  bilious  state  of  the  sys- 
tem. The  same  thing  may  be  said  of  occasional  pain  in  the  throat  arising  from  a con- 
gested state  of  its  mucous  membrane.  5.  The  epidemic  was  almost  universal,  sparing 
no  age,  from  the  infant  at  the  breast  to  men  in  advanced  life;  and  the  same  account  is 
given  from  the  other  places  in  Syria  which  it  has  visited.  But  in  no  case  could  death 
be  directly  traced  to  it,  though  in  some  instances  it  seems  to  have  stirred  up  to  a fatal 
result  some  old  or  latent  disease,  or  it  may  have  acted  as  a predisposing  cause  of  a sub- 
sequent and  serious  illness  ending  in  death.  The  severest  case  I saw  was  accompanied 
by  some  delirium  and  a considerable  amount  of  inflammation  of  the  testicles,  which  had 
to  be  leeched.  In  some  instances  it  was  attended  with  sore  throat  and  enlargement  of 
the  lymphatic  glands  of  the  neck.  In  one  young  woman  it  seems  to  have  produced 
temporary  insanity  for  a few  days.  As  a general  rule,  the  patient  was  confined  to  his 
bed  only  two  or  three  days.  Perspiration  was  always  useful  in  mitigating  the  febrile 
symptoms  and  the  attendant  pains,  but  it  was  never  so  critical  as  in  intermittent  fever. 
6.  One  more  point  remains  to  be  noticed,  and  that  is  the  question  of  the  infectiousness  of 
dengue.  The  fact  that  it  spread  from  an  infected  centre  to  the  neighboring  towns  and 
villages,  as  we  have  shown  in  the  early  part  of  this  paper,  and  that  when  it  came  into 
a family  it  attacked  all  its  members,  with  hardly  an  exception,  one  after  the  other,  in 
the  course  of  a few  days,  points  very  strongly  to  the  belief  that  dengue  fever  is  the 
most  infectious  of  all  diseases.  I know  hardly  any  instance  in  which  there  was  expos- 
ure to  it  during  its  height  of  prevalence  without  the  person  succumbing  to  its  influence 
of  communicability.  Mothers  and  nurses  gave  it  to  the  youngest  infants,  who,  with 
few  exceptions,  had  the  characteristic  eruption.  Sir  W.  R.  E.  Smart,  who  has  exten- 
sively studied  a number  of  its  visitations  and  given  a detailed  account  of  them,  says: 
“ In  the  whole  of  this  wide  dissemination  there  was  sufficient  evidence  of  its  infectious, 
if  not  of  its  contagious,  properties.”  ( Transactions  of  the  Epidemiological  Society  of 
London,  Yol.  IV,  part  i.)  The  medium  of  infection  seems  to  be  more  the  air  than  con- 
taminated water,  but  what  this  “contagium  vivurn”  is,  I could  not  discover.  The 
examination  of  the  blood  by  the  microscope  during  the  fever  revealed  no  disease  germs, 
though  there  was  an  alteration  in  the  form  of  the  corpuscles.  The  exposure  of  every 
one  was  so  great  and  so  constant  that  it  is  difficult  to  say  what  the  period  of  incubation 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  409 


•was.  A few  persons  who  took  the  infection  with  them  to  the  mountain  villages  which 
were  free  of  the  disease,  and  did  not  foil  ill  before  the  tenth  day  after  their  arrival, 
would  show  that  this  was  the  utmost  limit,  though  the  usual  time  was  probably  not 
much  more  than  two  or  three  days. 

I have  already  stated  that  the  epidemic  in  Bsyrout  began  in  September  and  ended 
in  December,  its  height  being  in  October;  and  from  this  and  from  the  history  of  former 
visitations,  and  the  fact  that  it  has  been  hitherto  limited  to  tropical  and  southern  lati- 
tudes, viz.,  India,  the  West  Indies,  Brazil,  the  Southern  United  States,  Egypt  and 
Syria,  Zanzibar  and  once  Malta,  and  that  at  no  time  did  it  spread  in  villages  of  the 
Lebanon  higher  than  2000  feet,  where  the  air  is  cool  and  dry,  it  would  appear  that  the 
most  favorable — if  not  essential — condition  for  its  importation  and  extension  is  a warm 
and  moist  climate.  This  will  probably  explain  why  Europe,  with  the  exception  of 
Spain,  has  been  spared  a visitation  from  this  eruptive  fever. 

Respecting  the  treatment  of  dengue,  it  does  not  appear  to  me,  from  the  short  and 
definite  course  it  runs,  that  it  requires  much  more  than  something  simple  and  symp- 
tomatic. If  biliary  symptoms  are  prominent,  give  an  emetic  followed  by  a saline  purge, 
a hypodermic  injection  of  morphia  or  a dose  of  chloral  at  night,  for  the  insomnia  and 
severe  pains.  Quinine  or  some  tonic  to  help  on  the  convalescence. 

Note. — Surgeon-general  Maclean,  in  his  late  work  on  tropical  diseases,  recommends  for  dengue 
one  drop  of  tinct.  of  aconite  every  ten  minutes,  till  head  is  relieved,  and  the  affected  joints 
smeared  with  chloroform  and  belladonna — ice  to  the  head  and  tepid  sponging  of  the  body. 
Quinine  and  salicylate  of  soda  were  both  tried  in  the  acute  stage  during  the  epidemic  in  Egypt, 
but  without  any  good  result.  In  my  own  practice  it  seemed  to  me  that  in  the  great  majority  of  the 
cases  I had  to  treat,  an  emetic  of  antimony  tartrate  and  ipecacuanha  followed  by  a mercurial 
purge  often  aborted  the  disease. 

The  history  of  dengue  in  Egypt  was  pretty  much  what  it  was  in  Syria,  i.  e.,  everybody  was 
affected  by  it,  although  many  of  those  attacked  paid  no  attention  in  any  way  to  their  symptoms. 

To  prove  its  transmissibility  by  human  intercourse,  we  had  a remarkable  example  of  this 
during  the  1880  epidemic  in  Cairo. 

When  the  epidemic  was  about  its  height  (end  of  August),  a contingent  of  Egyptian  troops 
were  sent  from  Cairo  to  a town  in  the  Delta  called  Damanhour,  where  the  malady  broke  out 
among  the  soldiers,  and  spread  from  them  through  the  town,  and  about  the  middle  of  September 
some  of  this  garrison  was  sent  to  Alexandria,  and  from  that  date  dengue  was  registered  in  that 
town.  (J.  A.  S.  G.) 

DISCUSSION. 

Dr.  McLaughlin,  of  Austin,  Texas,  demonstrated  under  the  microscope  his 
preparations  of  the  microorganism  which  he  conceives  to  be  the  cause  of  dengue. 
The  following  is  a brief  outline  of  his  remarks 

In  1885  a severe  epidemic  of  dengue  fever  prevailed  in  the  State  of  Texas, 
which  was  remarkable  for  its  violence  and  the  rapidity  of  its  spread.  The  clinical 
symptoms  of  the  disease  as  observed  during  the  prevalence  of  this  epidemic,  in  the 
main  agree  with  those  described  in  Dr.  Wortabet’s  paper  just  read  by  Dr.  Grant- 
Bey.  In  addition  to  those  enumerated  in  the  paper,  there  were  frequently  mani- 
fested in  the  Texas  epidemic  hemorrhages  from  various  portions  of  the  body,  a 
disposition  to  miscarriages  and  glandular  enlargements;  these  glandular  enlargements 
were  frequent  sequelae  of  this  disease.  From  the  epidemic  character  of  this  disease, 
its  infectiousness  and  clinical  history,  I was  led  to  suspect  that  its  infection  was  a 
microbe,  which  could  be  conveyed  by  air  currents,  individual  contact  or  infected  goods. 
That  this  microbe  found  in  the  blood  a suitable  environment  for  its  growth  and  repro- 
duction, that  through  its  fermentive  action  ptomaines  were  formed,  which  gave  rise 
to  the  pyrexia  and  other  symptoms  and  conditions  characteristic  of  the  disease. 


470 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


To  submit  this  opinion  to  practical  tests,  I made  a series  of  investigations,  with 
the  following  results  : — 

1.  I examined  blood,  microscopically,  directly  from  the  veins  of  persons  suffering 
from  dengue  in  its  various  stages;  this  blood  was  obtained  from  many  (about  twenty) 
different  individuals. 

2.  Using  necessary  precautions  to  exclude  alien  germs  and  obtain  chemical  clean- 
liness, I introduced,  upon  the  point  of  a sterilized  platinum  wire,  a small  fraction  of  a 
drop  of  dengue  blood  into  test  tubes  containing  sterilized  culture  jelly,  and  grew 
upon  the  jelly  the  microorganisms  (staphylococci)  which  the  blood  contained  and 
which  seem  peculiar  to  this  disease. 

3.  Using  all  necessary  precautions  against  the  introduction  of  any  foreign  ele- 
ments, I aspirated  into  a series  of  Liebig’s  potash  bulbs  the  blood  directly  from  the 
arm  of  a dengue  patient.  I then  hermetically  sealed  these  bulbs  and  allowed  those 
microorganisms  which  the  blood  contained  to  grow  upon  it  as  a nutritive  medium 
(the  temperature  was  constantly  maintained  at  100°  F.).  At  the  expiration  of  six 
months  the  first  bulb  was  removed  with  the  blow-pipe  and  its  contained  blood 
examined  with  high  powers,  the  preparations  being  stained  and  some  cases  not 
stained.  The  same  microorganisms  found  in  the  blood  directly  drawn  from  the  arm 
of  the  fever  patients  and  grown  pure  on  the  culture  media  were  also  found  in  the 
blood  obtained  from  this  bulb.  It  is  not  possible,  in  the  time  allowed,  to  enter  into 
the  technique  of  these  investigations;  suffice  it  that  every  precaution  was  used  to 
insure  cleanliness  and  exclude  alien  germs,  in  the  various  investigations  which  were 
made;  peculiar  affinities  and  antagonisms  were  shown  to  exist  bet  ween  these  microbes 
and  the  basic  aniline  dyes.  These  matters,  together  with  a description  of  the  modes  of 
generation  and  peculiar  grouping  of  these  microorganisms,  as  well  as  the  manner  of 
conducting  these  experiments,  will  be  found  in  a paper  read  in  Section  on  General 
Medicine  of  the  American  Medical  Association,  held  in  St.  Louis,  May,  1886. 

Dr.  J.  F.  Y.  Paine,  of  Galveston,  Texas. — The  admirable  paper  of  Dr.  John 
Wortabet  leaves  little  to  be  said  on  the  subject  of  dengue  ; yet  there  are  some  points 
connected  with  the  clinical  history  of  that  protean  disease,  which  were  either  absent 
in  the  epidemics  referred  to,  or  omitted  by  the  author. 

The  epidemic  in  Texas  in  1885  does  not  confirm  the  conclusions  of  Dr.  Worta- 
bet with  reference  to  the  habitat  and  atmospheric  conditions  essential  to  the  spread 
of  dengue.  In  that  year  every  interior  city  and  town  in  the  State  was  invaded,  and  ■ 
the  period  of  its  prevalence  was  characterized  by  unusual  dryness.  San  Antonio, 
Austin  and  Dallas,  ranging  in  altitude  from  600  to  900  feet  above  the  sea  level,  and 
distinguished  for  the  uniform  dryness  and  salubrity  of  their  climate,  suffered  in  an 
unusual  degree,  at  least  three-fourths  of  the  entire  population  of  those  cities  having 
been  attacked. 

Intercurrent  complications  were  by  no  means  infrequent.  Pleuritis  and  peritoni- 
tis were  observed  in  a number  of  instances,  of  aggravated  type.  Glandular  swell- 
ings— the  cervical  lymphatics  especially — were  of  common  occurrence  ; and  it  was  a 
matter  of  frequent  observation  that  the  salivary  glands  were  involved,  the  parotids 
most  generally.  I saw  a number  of  examples  in  which  the  inflammatory  action  of 
the  parotids  resulted  in  abscess.  The  inguinal  glands  were  exceptionally  affected. 
Hemorrhages  from  mucous  membranes  were  noticed  in  numerous  instances,  most 
commonly  from  the  nose,  throat  and  bowels. 

Several  physicians  in  Galveston,  including  myself,  attended  a number  of  patients 
who  suffered  from  serious  hemorrhage  from  the  colon,  the  source  being  clearly  defined 
by  the  tenderness  and  thickened  state  of  the  walls  of  that  viscus.  ILematemesis  took 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  471 

place  iu  the  practice  of  several  physicians.  I saw  a few  such  cases.  The  vagina  or 
gterus,  or  both,  seemed  to  bear  the  brunt  of  this  congestive  action,  as  manifested  by 
the  frequent  sanguineous  exudations  from  those  parts.  It  often  happened  that  women 
menstruated  out  of  their  regular  turn,  sometimes  profusely,  and  suffered  from 
menorrhagia  when  seized  at  a normal  epoch.  Old  women  long  past  the  menopause 
were  known  to  lose  blood  from  their  genitalia.  Miscarriages  at  every  term  of  preg- 
nancy occurred. 

The  universal  involvement  of  the  mucous  membranes  allies  it  with  the  catarrhal 
affections. 

The  duration  of  dengue  does  not,  as  a rule,  exceed  five  to  eight  days,  but  instances 
are  not  uncommon  in  which  the  disease  drifts  into  a long  type  of  fever  closely 
resembling  typhoid.  Dysentery  is  an  occasional  sequel.  An  irritable  or  hyperaes- 
thetic  condition  of  the  alimentary  tract  has  been  known  to  constitute  a distressing 
and  persistent  sequence.  The  special  senses  have  at  times  suffered,  smell  and  taste 
being  paralyzed. 

Two  months  are  required  to  effect  complete  recovery  from  a well-marked  attack 
of  dengue. 

Quinine  is  generally  sufficient  to  relieve  the  distressing  myalgia,  though  opiates 
are  occasionally  demanded. 

Dr.  Grant,  in  closing  the  discussion,  said  that  dengue  seems  to  be  severer  in 
Texas  than  in  Egypt.  Liver  troubles  in  Egypt  complicate  all  diseases,  and  quinine 
given  without  first  attending  to  the  liver  seems  to  aggravate  the  disease. 

i 

PRESENTED  by 

Dr,  CHAS,  W.  HITCHCOCK. 

FROM  THE  LIBRARY  OF 

r>’T  H O.  HITCHCOCK. 


472 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


THIRD  DAY. 


SOME  POINTS  ON  THE  GROWTH  OF  PREVENTIVE  MEDICINE 

IN  GREAT  BRITAIN. 

QUELQUES  APERf  US  SUR  LE  PROGRES  DE  LA  MEDECINE  PREVENTIVE  DANS 

LA  GRANDE  BRETAGNE. 

EINIGE  BEMERKUNGEN  UBER  DAS  WACHSTHUM  DER  ALLGEMEINEN  PROPHYLAXE  IN 

GROSSBRITANNIEN. 

BY  BENJAMIN  WARD  RICHARDSON,  M.D., 

Of  London,  Eng. 

“'The  English  people,”  so  one  of  our  old  school  books  tells  ns,  “being  cut  off  by 
the  sea  from  the  rest  of  the  world,  commenced  to  be  mariners  from  necessity.  But 
that  which  at  first  seemed  an  inconvenience  turned  out,  in  the  end,  so  much  to  our 
advantage,  that  for  a long  time  it  made  England  the  lord  of  the  ocean.” 

We  might  say  now,  in  regard  to  sanitation,  that,  thrown  upon  her  own  resources, 
England,  by  necessity,  took  up  sanitation,  and  pursued  it  so  practically  and  diligently 
that  she  may,  in  results,  safely  declare  her  sanitation  to  be  equal,  on  the  whole,  to  that 
of  any  other  country. 

Sanitation  here  has  been  learned  chiefly  through  the  incidents  of  war,  and  the 
destruction  of  life  by  disease  in  our  armies,  which  has  exceeded  that  by  the  sword. 
The  terrible  lessons  taught  by  the  ill-fated  Walcheren  expedition  were  the  first  that 
were  duly  appreciated.  They  and  some  others  of  minor  but  significant  character  led 
our  army  surgeons  and  physicians  to  write  and  to  speak  in  a manner  quite  novel  to  tbe 
rest  of  their  medical  confreres.  Henuen  and  Pringle — the  last  named,  especially — 
were  led  to  give  forth  a knowledge  of  preventive  measures  which  have,  even  in  these 
days,  not  been  surpassed.  Their  experience  led  the  way  to  study,  but  not  to  any  great 
advancement. 

Another  lesson  was  demanded,  and  that  came  with  the  Crimean  campaign,  which, 
with  all  its  disasters,  proved  one  of  the  most  important  victories  for  science  that  England 
has  ever  won. 

Meantime,  attention  was  turned  to  sanitation  iu  another  direction.  The  jails  of  this 
country  were  the  great  centres  of  spreading  plagues,  particularly  of  typhus  fever.  Our 
illustrious  philanthropist,  John  Howard,  penetrated  these  stables  of  death,  and,  by 
the  exposure  ite  made  of  them,  led  the  sanitary  physician  to  look  into  the  subject  of 
construction  of  buildings  and  lodgment  of  residents  iu  regard  to  the  production  of  fatal 
diseases  within  the  four  walls  of  institutions  and  houses  in  which  people  are  domiciled 
and  enclosed. 

Again,  as  we  became  an  industrial,  manufacturing  nation,  as  well  as  an  agricultural, 
the  minds  of  philanthropists  were  drawn  to  the  influence  of  occupation  ou  the  health 
of  those  persons  who  were  doomed  to  live  in  the  factories  of  the  nation,  and  the  import- 
ant Legislative  Act  of  1802,  the  first  of  a series  of  acts  bearing  ou  sanitation,  affords 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  473 


proof  of  the  advance  which,  in  the  early  part  of  this  century,  was  being  made  toward 
the  application  of  a set  of  new  sanitary  laws  for  the  good  of  the  kingdom  at  large. 

These  were  the  first  beginnings  of  our  sauitary  progress  on  this  side  the  Atlantic. 
They  were  iu  the  first  instance  essentially  insular  in  their  character.  They  sprang,  as 
it  will  be  seen,  out  of  necessity,  and  in  time  they  made  a science  for  themselves. 

As  the  second  half  of  the  century  drew  near,  a kind  of  social  revolution  was  intro- 
duced by  the  revision  of  the  old  poor  laws,  which  had  been  in  existence  from  the  reign 
of  Elizabeth,  and  had  become  so  entirely  out  of  the  time  that  nothing  except  a revolu- 
tionary reform  could  be  of  any  service.  In  the  end,  the  management  of  the  poor,  hitherto 
entrusted  to  several  thousand  local  boards,  was  concentrated  into  six  hundred  central 
boards  in  special  districts  called  Unions.  An  astonishing  change.  The  preliminary  work 
for  this  change  led  to  an  exposition  of  startling  quality  and  magnitude.  Fortunately, 
the  chief  of  this  inquiry  (a  man  now  of  eighty-seven  summers  who  still  lives  among 
us),  Edwin  Chadwick,  was  most  admirably  fitted  for  the  duty,  and  his  report  to  the 
Government,  in  1847  on  “ the  sanitary  condition  of  the  laboring  classes,”  laid  a new 
foundation,  which  has  been  as  useful  as  a sanitary  guide  to  other  nations  as  to  our  own 
from  which  it  emanated. 

From  the  date  of  that  inquiry  preventive  medicine  in  England  has  become  a dis- 
tinct branch  of  national  learning  and  culture,  and  the  results  have,  even  by  this  time, 
become  so  remarkable  that  with  another  four  similar  decades  of  progress  we  may  look 
upon  England  as  a new  country  of  healthiness  and  social  purity. 

It  will  serve  best  to  illustrate  this  statement  by  a few  details  of  results. 

In  some  of  our  English  troops  lying  at  home  during  the  period  of  the  Crimean 
campaign,  the  mortality,  chiefly  from  phthisis  pulmonalis,  was  greater  than  the  mortal- 
ity of  those  who  were  enduring  all  the  dangers  and  exposures  of  the  campaign.  Now 
such  a position  of  things  is  impossible  ; the  life  of  our  soldiers  at  home,  in  all  quarters 
is  almost  equal  in  value  to  that  of  the  most  favored  classes  ; is  better  than  that  of  all 
classes ; and  is  one-third  better  than  that  of  the  classes  from  which  the  soldiers  are 
drawn  for  service. 

A death  rate  of  twenty  per  1000  three  decades  ago  was  reduced  in  last  decade  but 
one  to  18  per  1000,  and  in  the  very  last  decade,  to  12.51,  with  a sick  rate  brought  down 
from  50  per  1000  to  39.38.  The  same  benefit  has  been  extended  to  the  colonial  armies. 
A death  rate  of  30  in  the  1000  in  last  decade  but  one  has  been  reduced  to  10.7,  with  a 
lowering  of  the  sickness  rate  from  70  per  1000  to  39.81. 

The  most  extraordinary  reform  has,  however,  taken  place  in  India.  Thirty  years 
ago,  the  mortality  in  our  Indian  army  was  such  that  in  an  article  which  I then  wrote 
on  the  “ British  Juggernaut  in  India,”  I could  only  compare  a regiment  of  English 
soldiers  there  to  the  Irishman’s  famous  knife,  which  retained  its  continuity  by  the 
rapid  exchange  of  a new  haft  to  a new  blade,  and  then  a new  blade  to  a new  haft. 
In  1853,  the  startling  fact  was  elicited  that  the  Honorable  East  India  Com- 
pany’s European  regiments  were  absorbed  and  required  to  be  renewed  every  eight 
years,  while  in  her  Majesty’s  regiments  the  same  absorption  and  renewal  was 
required  every  twelve  years.  One  officer,  Dr.  F.  S.  Aimott,  reported  that  he 
had  seen  a regiment  decimated  by  disease  in  nine  days,  and  reduced  in  the  space 
of  a year  at  the  rate  of  215  per  1000,  which  would  have  annihilated  it  in  less 
than  five  years.  This  able  officer  considered  that  the  loss  of  a regiment  at  the  rate 
of  47  in  the  1000  during  a year  of  service  was  au  unusual  success,  and  in  this  estimate 
he  was  certainly  well  within  the  mark.  A death  rate  of  100  per  1000  of  the  mean 
force  existed  for  a period  considerably  later  than  that  above  stated.  But  when  the 
preventive  system  got  good  hold  the  rate  became  rapidly  reduced,  so  that  between  the 
years  1869  and  1878  it  fell  to  56.67  in  the  1000,  with  a saving  of  sickness  during  that 
period  of  over  25,000.  The  improvement  has  shown  itself  equally  iu  our  prison 


474 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


departments,  and  to  some  minds  even  in  a more  striking  form,  for  now,  by  a strange 
revision  of  social  and  hygienic  conditions,  the  prisons  of  England  have  become  the 
cynosures  of  health.  I am  accustomed  to  keep  my  attention  systematically  on  the 
prison  returns,  and,  to  the  best  of  my  knowledge,  there  has  been  no  outbreak  of  any  con- 
tagious disease  in  the  whole  of  the  past  five  years.  The  fact  speaks  volumes,  because 
it  shows  that  nothing  hut  purity  of  life  is  required  to  sweep  away  all  the  great  plagues 
from  the  face  of  the  earth.  If  in  one  English  prison,  where  the  social  conditions  are  so 
sad  and  disastrous,  plagues  can  he  exorcised,  surely  in  a better  world  the  same  things 
can  he  done,  and  ought  to  he  done  if  the  blessing  of  good  health  is  not  to  he  added  as 
a premium  ou  crime. 

In  our  manufacturing  life  great  sanitary  improvements  have  also  been  carried  out. 
Not  to  the  same  extent  as  in  the  barracks  and  in  the  prisons,  hut  to  as  great  an  extent 
as  could  be  expected  among  men  uninformed,  prejudiced  and  free;  for,  much  as  we 
love  liberty,  the  exercise  of  free  will  without  knowledge  is  a mighty  influence  for  evil 
against  the  earnest  sanitary  reformer. 

In  the  above  I have  indicated  the  bright  side  of  the  sanitary  question  in  England, 
and  without  wishing  to  depreciate  that,  being  indeed  very  proud  of  it,  as  is  natural  to 
one  who  has  labored  to  bring  it  about,  I must  report  to  you  that  there  remains  a vast 
work  to  be  done  here.  The  great  classes  of  our  people  are  enormously  death-rated 
still.  Mr.  Chadwick  and  I not  long  since  made  an  analysis  of  three  registration  dis- 
tricts in  London,  with  a view  to  learn  the  death  rate  question  in  classes  as  a guide  to 
the  salubrity  of  classes.  We  took  St.  George’s,  Hanover  Square,  Westminster  and  the 
Strand  for  the  year  1878,  and  we  found  in  them,  combined  as  one,  a general  death 
rate  22.7  per  1000.  We  then  examined  into  the  mean  age  at  death  of  the  different 
classes  with  the  result  of  finding  as  follows  : — 

For  gentry  and  professional  classes,  55. 8 years. 

Salaried  clerks,  commercial  clerks,  merchant  tradesmen,  33.2  years. 

Domestic  servants,  34.3  years. 

Artisans  and  others  of  the  wage  or  working  classes,  28.9  years. 

By  a further  inquiry,  we  discovered  that  while  the  differences  in  the  above  classes 
in  regard  to  life,  were  most  marked  in  the  young,  the  disparity  extended  to  and  through 
the  other  periods  of  life.  Thus  the  children  of  the  well  to  do  who  had  passed  the  age 
of  five  years  reached  on  an  average  to  the  age  of  63  years;  the  children  of  salaried 
clerks  to  47  years;  the  children  of  tradesmen  to  54.9  years;  the  children  of  servants  to 
51  years;  and  the  children  of  artisans  and  wage  people  to  50.7  years. 

I have  only  time  to  quote  the  above  facts  in  proof  of  the  statement  that  we  have 
much  to  do,  notwithstanding  all  that  has  been  done;  and  to  state  the  belief,  to  which  I 
have  been  brought,  that  now  the  sanitarian  must  either  wait  for  the  statesman  or 
become  the  statesman  himself.  In  this  country  the  affairs  of  State  block  the  way  to 
affairs  of  health.  With  you  I hope  it  is  differently  ordained.  If  it  is,  you  will  soon  be 
ahead  of  your  mother  country  in  relation  to  that  national  health  which  is  the  only  true 
national  wealth.  Saluti  Americans. 


In  accordance  with  the  request  of  its  author,  the  preceding  paper  was  read  by 
the  President  of  the  Fifteenth  Section  of  the  Ninth  International  Medical  Congress, 
who  embraced  this  occasion  to  express  his  profound  regret  that  Dr.  Benjamin 
Ward  Richardson  had  been  prevented,  by  his  pressing  and  important  duties,  from 
fulfilling  his  promise  of  crossing  the  Atlantic  and  taking  an  active  part  in  the  delib- 
erations of  the  Section  on  Public  and  International  Hygiene. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  475 


Dr.  Jones  said  that  Dr.  Benjamin  Ward  Richardson  was  one  of  the  first  of  the 
eminent  scientific  men  of  Europe  to  signify  his  hearty  acceptance  of  the  invitation 
of  his  American  brethren  to  take  an  active  part  in  the  deliberations  of  the  Ninth 
International  Medical  Congress. 

Vice-President  A.  N.  Bell,  of  New  York,  paid  a well-merited  tribute  to  Dr. 
Richardson  and  to  Dr.  Edwin  Chadwick.  Foremost  among  the  promoters  of  the 
science  of  preventive  medicine  in  England  was  Dr.  Edwin  Chadwick,  under  whose 
influence  practical  sanitation  exhibited  such  signal  advances  as  to  have  resulted  in 
making  it  essentially  a department  of  the  Government. 

Dr.  Joseph  Jones  moved  that  the  thanks  of  the  Section  on  Public  and  Inter- 
national Hygiene  be  respectfully  tendered  to  Dr.  Benjamin  Ward  Richardson,  of 
London,  for  his  practical  and  valuable  paper.  Unanimously  adopted. 

In  accordance  with  the  resolution  the  following  letter  has  been  addressed  to  Dr. 
Benjamin  Ward  Richardson. 

Dr.  Benjamin  Ward  Richardson,  25  Manchester  Square,  London. 

Dear  Sir. — We  have  the  honor  to  inform  you  that  on  the  third  day  of  the  Congress  your  letter 
and  paper,  entitled  “Some  Points  on  the  Growth  of  Preventive  Medicine,”  were  read  before  the 
Section  of  Public  and  International  Hygiene,  by  its  president. 

At  its  conclusion  remarks  were  made,  reciting  the  great  services  which  had  been  rendered  to 
the  cause  of  preventive  medicine  by  yourself,  and  a resolution  was  unanimously  adopted,  in- 
structing the  President  and  Secretary  to  convey  to  you  a vote  of  thanks,  passed  by  the  Section, 
for  your  very  valuable  contribution. 

In  performing  this  very  agreeable  duty,  we  beg  leave  to  add  this  expression  of  our  great  per- 
sonal esteem,  and  to  remain,  dear  Sir,  Yours  very  respectfully, 

[Signed]  Joseph  Jones,  m.d., 

President  Section  Public  and  International  Hygiene. 

Walter  Wyman,  a.m.,  m.d., 

Surgeon  U.  S.  Marine  Hospital  Service,  Secretary. 


LE  VACCIN  DE  LA  FIEVRE  JAUNE : RESULTATS  STATISTIQUES 
DES  INOCULATIONS  PRATIQUEES  AVEC  LA  CULTURE  ATTE- 
NUEE  DU  MICROBE  DE  LA  FIEVRE  JAUNE. 

THE  GERM  OF  YELLOW  FEVER.  STATISTICS  OF  RESULTS  OF  INOCULATIONS 
PRACTICED  WITH  THE  ATTENUATED  CULTURE  OF  THE  MICROBE 

OF  YELLOW  FEVER. 

DIE  INFECTIONSKEIME  DES  GELBEN  FIEBERS.  STATISTISCHE  RESULTATE  DER  INOCULA- 
TIONEN  MITTELS  VERDUNNTER  KULTUREN  DES  GELBEN  FIEBERMICROBEN. 

PAR  LE  DR.  DOMINGOS  FREIRE, 

Riode  Janeiro,  Brazil. 

Je  suis  bien  heureux  cl ’avoir  l’opportunite  tie  presenter  devant  vous  le  resultat  de 
mes  experiences  surla  fievre  janne.  Comptantsur  le  prestige  de  l’autorite  des  savants 
qui  se  trouvent  reunis  a l’heure  qu’il  est  dans  cette  grande  metropole  de  la  civilisation 
Americaine  la  communication  que  j’ai  1’honneur  de  vous  offrir  portera  en  elle  l’espoir 
de  faire  avancer  d’un  pas  considerable  la  question  medicate  la  plus  palpitante  pour  les 


476 


NINTH  INTERNATIONAL  MEOICAL  CONGRESS. 


deux  Am6riques,  ainsi  que  pour  le  monde  en  general,  c’est-a-dire,  l’extinction  de  cet 
aftreux  fieau  de  la  race  humaine,  devaut  lequel  on  ne  peut  s’empecher  de  fremir  en 
songeant  aux  ravages  dont  il  est  la  cause  chaque  annee. 

Yous  savez  tous  que  j’ai  annonce  depuis  1880,  que  la  fifevre  jaune  etait  due  a la  pre- 
seuce  dans  l’organisme  d’uu  etre  infiniment  petit,  siegeant  dans  le  sang  et  dans  la 
trame  la  plus  intime  des  tissus,  se  re  ve  lant  dans  les  liquides  des  secretions,  et  causant 
par  suite  de  son  6volution  des  desordres  qui  terminent  souvent  par  la  mort.  Depuis 
cette  date  j ’ai  poursuivi  sans  cesse  mes  recherches  non  seulement  dans  le  but  de  demon- 
trer  la  transucissibilite  du  microbe  amaril,  mais  encore  dans  le  but  d’obtenir  son  atte- 
nuation et  de  le  transformer  en  vaccin.  J’ai  publie  neuf  memoires  sur  ces  differents 
sujets,*  outre  un  rapport  intitule  Doctrine  Microbienne  de  la  Fievre  Jaune  et  ses  Inocu- 
lations Preventives,  dans  lequel  j’ai  condense  toutes  mes  id6es  sur  la  pathologie  et  la 
prophylaxie  de  la  fievre  jaune.  Deux  de  ces  travaux  out  ete  faits  en  collaboration  avec 
MM.  Paul  Gibier  et  Ch.  Rebourgeon,  eleves  distingues  tous  les  deux  de  l’emineut 
savant  M.  Pasteur  et  qui  ont  bien  voulu  s’associer  it  moi  pendant  mon  sejour  & Paris 
cette  ann6e  meme.  Dernibrement,  it  Rio  Janeiro,  j’ai  continue  les  memes  recherches 
avec  notre  distingue  confrere  et  votre  compatriote  M.  le  Dr.  Sternberg,  qui,  comiue 
vous  le  savez,  a ete  envoy6  en  mission  par  le  Gouvernement  de  l’Union  Americaine  afin 
de  se  mettre  au  courant  sur  le  resultats  de  mes  etudes.  J’accomplis  ici  un  devoir  eu 
exprimant  toute  ma  reconnaissance  pour  l’interet  et  le  zele  indeniables  qu’a  developpes 
ce  savant  medecin,  ainsi  que  pour  le  concours  efficace  qu’il  m’a  prete. 

Yous  voyez  done,  Messieurs,  que  la  doctrine  que  je  soutiens  sur  la  nature  et  la  pro- 
phylaxie de  la  fikvre  jaune  a ete  le  fruit  d’une  longue  serie  d’experiences  poursuivies 
assidument  pendant  sept  annees.  Que  cette  consideration  puisse  servir  de  justification 
it  la  eonfiance  assuree  que  j’ai  dans  les  faits  que  j’ai  observes  non  seulement  par  rapport 
a l’etiologie  et  la  pathogenie  de  la  maladie,  mais  aussi  sur  le  point  de  vue  de  la  pratique 
des  inoculations  preventives  que  j’ai  proposees. 

Aprfes  ce  rapide  inventaire  des  materiaux  accumules  sur  la  question  je  vous  prie  de 
vouloir  bien  m’entendre  sur  quelques  details  qui  feront  l’objet  de  cette  communication. 
Je  diviserai  mon  exposition  dans  plusieurs  parties  afin  d’embrasser  methodiquemeut 
toutes  les  reflexions  jusqu’ii  un  certain  point  heterogenes  que  j’ai  a developper. 

1°  HISTOIRE  NATURELLE  DU  MICROBE  AMARIL.  SA  CLASSIFICATION.  SON 

EVOLUTION.  SA  CULTURE.. 

L’histoire  naturelle  de  tous  les  microbes  en  general  est  encore  trks  obscure.  La 
science  commence  & peine  il  balbutier  les  premiers  mots  sur  cette  6tude  aussi  ardue  que 
delicate.  Nous  pouvons  meme  affirmer  qu’elle  a et6  injustemeut  oubliee,  les  observa- 
teurs  ayant  prefer^  jusqu’ici  de  creer  les  methodes  techniques  destinees  a chercher  et 
cultiver  les  microbes  avant  de  s’appliquer  il  connaitre  il  fond  leur  manifere  de  vivre, 
leurs  caractcres  physiques  et  chimiques,  urs  moeurs  et  leur  physiologie.  Cet  oubli  est 
sans  doute  une  des  causes  les  plus  importautes  de  la  confusion  qui  regue  dans  les  clas- 
sifications des  orgamsmes  infiniment  microscopiques.  Chaque  auteur  se  croit  autorisA 
ii  presenter  sa  classification,  basee  elle  meme  sur  des  douuees  incomplfetes,  telles  que  les 
caracteres  de  forme,  de  grandeur,  de  groupement  eu  colonies,  aussi  variable  les  uns  que 
les  autres,  quelquefois  pour  le  meme  micro-organisme.  Aussi  voyons-nous  tous  les 
jours  se  repeter  la  singuliere  anomalie  d’un  meme  etre  microscopique  plac6  dans  des 
classes  tres  differentes,  selon  le  caprice  des  classifications  ; et  tel  microbe  qu’on  regar- 
dait  aujourd’hui  comme  un  microcoque  sera-t-il  peut-etre  demain  relegue  dans  la  divi- 
sion des  bacilles,  ainsi  qu’il  est  dejit  arrive  au  microcoque  du  ehoKjra  des  poules  que 
quelques  auteurs  allemands  pretendeut  inclure  dans  le  groupe  des  bacilles. 


* Ces  memoires  sont  les  suivantes. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  477 


Dans  l’affolement  de  communiquer  la  vitesse  d’une  locomotive  aux  recherches 
microbiologiques,  on  est  all6  jusqu’au  point  extreme  d’oublier  que  la  microbiologie 
n’est  qu’une  brancbe  de  la  botanique,  et  qu’il  est  encore  trop  tot  que  de  vouloir  divor- 
cer Pune  de  l’autre,  tout  l’iuteret  devant  etreau  contraire  que  les  botanistes  pretent  de 
leur  part  une  cooperation  active  dans  le  mouvement  scientifique  suivi  dans  cette  direc- 
tion. On  a p reclame  1’ emancipation  de  la  microbiologie  d’une  mauifere  tout-a-fait  prc- 
maturee.  On  a voulu  se  donner  le  plaisir  de  crcer  une  nouvelle  science,  sans  que  les 
fondements  de  son  organisation  eftssent  et6  jetes  sur  un  terrain  suffisamment  solide  ; le 
resultat  en  a 6t6  que  l’edifice  vacille  sur  ses  assises  et  qu’on  ignore  absolument  le  nord 
qu’il  faut  viser  pour  mener  it  un  bon  port  les  questions  bacteriologiques.  On  s’imagine 
;\  present  que  la  microbiologie  est  une  science  completement  autonome,  tout-a-fait 
independaute  des  lois  que  gouvernent  la  botanique,  erreur  desastreuse  qui  denature  le 
but  vers  lequel  doit  marcher  la  medecine  et  qui  cause  par  consequent  un  retard  lamen- 
table dans  son  evolution  progressive.  II  ne  faut  pas  croire  qu’un  etre  vivant  par  le  seul 
fort  qu’il  est  d’une  grandeur  infiniment  petite  et  qu’il  fait  son  habitat  dans  les  couches 
les  plus  lointaines  de  notre  organisme,  n’obeisse  pas  aux  memes  lois  biologiques  qui 
regissent  tous  les  autres  etres,  bien  plus  grands  qu’eux  et  qui  vivent  en  dehors  de  nous 
memes,  soit  a la  surface  de  la  terre,  soit  dans  la  profondeur  des  eaux.  Non,  les  micro- 
organismes,  comme  les  plantes  en  general,  doivent  avoir  un  certain  nombre  de  phases 
correspondant  aux  ages  de  leur  vie,  ils  doivent  se  nourrir  comme  toutes  les  plantes  aux 
depens  d’echanges  entre  le  milieu  dans  lequel  ils  plongent  et  les  materiaux  qui  font 
partie  de  leurs  propres  tissus,  tout  en  vivant  ils  doivent  secreter,  comme  tous  les  vege- 
taux,  de  certains  principes  utiles  il  leur  entretien,  ils  doivent  s’assimiler  les  substances 
forinees  dans  leur  interieur  par  suite  de  leur  elaboration  vitale,  et  excreter  d’un  autre 
cote  tous  les  principes  impropres  4 leur  nutrition,  representant  le  caput  mortuum  de 
leur  travail  organ ique. 

C’est  le  tort  des  medecins,  Messieurs  ; et  je  ne  suis  pas  suspect  dans  le  cas  present 
car  je  parle  contre  ma  profession,  et  par  suite  contre  moi-meme.  Mais  je  ne  peu  pas, 
m’empecher  de  reconnaitre  que  dans  toutes  les  epoques  les  medecins  ont  eu  le  grand 
tort  de  tacher  de  s’eloigner  toujours  le  plus  possible  des  sciences  naturelles  et  physico- 
chimiques.  Au  moment  merne  oh  nous  recevons  de  la  main  de  ces  sciences  les  plus 
grands  bienfaits,  qui  pourraient  faire  faire  un  grand  pas,  soit  h la  pathologie,  soit  h la 
clinique,  soit  a la  therapeutique,  voilh  que  nous  leur  tournons  le  dos,  ne  sachant  pas 
nous  profiter  de  toutes  les  richesses  que  ces  sciences  sauraient  nous  prodiguer  encore  da- 
vantage,  voilh  que  nous  nous  bertjons  dans  nos  anciennes  illusions,  et  crayons  pleins 
de  vanite  que  nous  n’avons  plus  de  besoin  de  leurs  services.  On  disait,  messieurs  que 
nous  sommes  des  ingrats  incorrigibles,  renontjaut  la  protection  d’uu  bienfaiteur  qui 
pourrait  nous  etre  utile  plus  tard  et  meconnaissant  la  valeur  des  dons  qu’il  nous  a 
accordes. 

Mais  voyons,  Messieurs,  qu’est-ce  que  c’est  un  microbe  ? 

C’est  un  vegetal  au  bout  du  compte  ; et  notre  devoir  serait  de  l’etudier  comme  tel, 
d’apres  les  memes  methodes  applicables  aux  vegetaux  microscopiques,  et  non  de  les 
considerer  comme  des  etres  extraordinaires,  presque  surnaturels,  obeissant  it  des  lois 
speciales  en  dehors  du  plan  general  trac6  par  la  nature.  Nous  devons  nous  rappeler 
que  la  medecine  n’est  qu’une  science  naturelle  ; venions  it  jamais  cette  tendance  air 
mysterieux  qui  a enveloppe  dans  d’epaisses  tenebres  les  questions  relatives  it  l’infection 
et  h la  contagion.  Suivons  pas  it  pas  la  nature,  etudions-la  dans  son  harmonie  d’en- 
semble,  et  une  fois  en  possession  des  microbes,  comme  nous  le  sommes,  ne  les  lachons 
pas  pour  courir  aprhs  les  memes  chimhres  qui  nous  ont  6gares  et  trompes  pendant  une 
si  longue  s6rie  de  sihcles  d’ignorance  et  de  scepticisme. 

Ferme  dans  ces  idhes,  j’ai  tach6  de  m’astreindre  aux  principes  g6n6raux  de  biolo- 
gie,  afin  de  classifier  et  suivre  revolution  du  microbe  amaril. 


478 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Quelques  naturalistes  sont  d’avis  que  les  microbes  appartiennent  au  royaume  des 
protistes  crbes  par  Glaecker,  espbce  de  groupe  hybride  oil  les  royaumes  vegetal  et  ani- 
mal se  confondent  entre  eux  dans  une  interference  de  caracteres  qui  me  semble  bien 
loin  d’exprimeria  verite.  S’il  est  vrai  que  par  suite  des  mouvements  qu’ils  exbcutent 
ainsi  que  par  la  composition  chimique  de  leur  protoplasme  les  microbes  nous  rappellent 
certains  infusoires,  et  que  par  la  composition  chimique  de  leur  enveloppe  et  la  resistance 
it  certains  reactifs,  tels  que  l’ammoniaque  et  la  potasse,  ils  nous  rappellent  les  cellules 
vegetales,  il  n’est  pas  moins  vrai  qu’aucun  des  caracteres  ci-dessus  n’est  exclusif  ni  aux 
animaux  ni  aux  plantes.  Certes,  on  connait  des  vegetaux  qui  jouissent  de  la  propriete 
d’executer  des  mouvements  assez  nets  et  qui  semblent  etre  meme  doues  d’une  irritabi- 
lity speciale  semblable  it  celle  des  animaux.  II  suffit  de  citer  it  l’appui  de  ce  que  je 
viens  de  dire  l’exemple  bien  connu  de  la  mimosa  pudica  et  celui  encore  plus  frappant 
de  la  disuda  muscipara  et  de  toutes  les  plantes  dites  carnivores,  ayant  le  singulier  pri- 
vilege d’attraper  leur  proie  dans  les  grilles  dont  leur  feuilles  sont  pourvues  et  plus  encore 
celui  de  digeref  comme  les  animaux,  la  viande  et  d’autres  substances,  ainsi  que  l’a  suf- 
fisamment  demontre  1’ eminent  Darwin.  Meme  chez  les  plantes  occupant  une  place 
elevee  dans  la  hierarchie  phytologique,  on  pourrait  en  rigueur  admettre  qu’elles  exe- 
cutent  des  mouvements.  En  effet,  il  est  impossible  de  concevoir  la  croissance  sans  un 
changement  de  place  dans  l’espace.  D’ailleurs  tout  le  monde  sait  que  it  P occasion  du 
printemps  qui  succbde  au  froid  excessivement  intense  des  regions  glaciales,  on  peut 
apprecier  a l’ceil  nu  l’eclosion  des  bourgeons  poussant  comme  par  enchantement  aux 
branches  des  arbres. 

Quant  il  la  composition  du  protoplasme  des  microbes,  nous  ferons  remarquer  que  la 
cellule  embryonnaire  de  tous  les  vegetaux  renferme  dans  son  iuterieur  un  protoplasme 
egalement  azote,  associe  ii  la  maticre  amylacee  et  it  d’autres  substances.  D’un  autre 
cote,  on  sait  que  la  cellulose  qui  constitue  la  membrane  enveloppante  des  microbes  ou 
tout  au  moins  ou  congenere  de  ce  principe  immediat  se  rencontre  aussi  dans  le  man- 
teau  des  Ascidiens  et  des  Tuniciens,  de  meme  que  dans  les  vers  it  soie,  dans  l’infusoire 
de  l’infusoire  connu  sous  le  nom  de  euglena  viridis  et  dans  les  corpuscules  de  Purkinje 
siegeaut  dans  les  ventricules  lateraux  de  notre  cerveau.  J’ai  done  mis  de  cote  le  royaume 
des  protistes  lorsque  j’ai  cherche  de  classifier  le  microbe  de  la  fibvre  jaune,  vu  que  je  le 
regarde  comme  inadmissible  it  l’etat  actuel  de  la  science,  et,  j’ai  prefere  de  la  placer 
dans  la  classe  des  algues,  en  m’appuyant  sur  l’autorite  de  savants  tels  que  Robin  et 
Littre,  Germain  St.  Pierre  et  d’autres.  En  1880,  epoque  oit  j’ai  decouvert  le  microbe 
amaril,  je  lui  ai  donne  de  cryptococcus  xanthogenicus,  parce  qu’il  m’a  offert  les  propri- 
ety s principals  qui  caracterisent  le  genre  cryptococcus.*  Modernenient  on  a cree  le 
le  genre  micrococcus  pour  designer  les  microbes  cellulaires  ou  ovo'ides,  cause  de  beau- 
coup  de  maladies  infectantes  et  contagieuses.  Pour  plusieurs  botanistes,  d’aprbs  ce  qui 
m’a  renseigne  le  Dr.  Pizarro,  Professeur  distingue  de  botanique  et  zoologie  it  la  Facul- 
ty de  Medecine  de  Rio  de  Janeiro,  le  genre  microcoque  ne  serait  que  le  meme  genre 
cryptococcus,  la  difference  consistant  it  peine  dans  la  reproduction  au  moyen  de  spores 
pour  celui-ci,  tandisque  les  microcoques  se  reproduiraient  par  bourgeonnement.  Un- 
certain nombre  d’auteurs,  tous  medecins  cliniciens  et  par  consequence  incompetents  it 
resoudre  des  questions  d’bistoire  naturelle,  se  sont  etounes  de  ce  j’efls  classify  mon 
cryptocoque  ou  microcoque  parmi  les  algues,  et  non  parmi  les  champignons  ou  schizo- 
myebtes.  Il  y a plus  qu’uue  question  de  mot  dans  cette  objection  ; je  peux  afliriner 
aujourd’hui  que  j’ai  parfaitemeut  raison,  ou  que  des  botanistes  du  rang  de  Cauvet,  de 
Van  Ermenghen,  Van  Tiegbeu  et  d’autres,  sont  d’accord  il  cousiderer  de  tels  micro- 


* “Les  criptococcus,  dit  Robin  (“Trnite  du  Microscope,”  p.  522  ct  890),  sont  a Vfitat  d'amas 
de  cellules  ovo'ides  ou  parfois  spheriques  juxtaposfios  en  amas,  en  series  plus  ou  moins  lougues 
ou  isolfies,  et  d’un  sujet  a Taatro  peuvent  etre  sous  nuolbole  ou  pourvus  d’un  nuclbole  brillant.” 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  479 


organismes  comme  appartenant  it  la  division  des  algues.  Ce  dernier  savant  s’est  expri- 
me  d’une  inauiere  positive  sur  ce  sujet  dans  un  congres  international  de  botanique 
reuui  il  y a quelques  annees,  ses  conclusions  ayant  fete  adoptees  par  cette  assemblee 
savante. 

Ceci  pose,  faisons  une  description  succinte  des  caractferes  du  microbe  amaril  et  de 
son  Evolution.  II  se  presente  bous  la  forme  monocellulaire,  commenijant  par  de  petits 
points  rouds,  presque  imperceptibles,  meme  avec  un  grossissement  supferieur  it  700 
diamfetres,  points  qui  peu-a-peu  vont  en  croissant,  refractant  fortement  la  lumifere,  ne 
tardant  pas  it  presenter  des  zones  obscures  sous  certaines  incidences  de  lumifere.  Ces 
petites  cellules  sont  circulates  (spheriques),  entourees  d’uu  rebord  ii  couleur  cendre  ou 
noir,  conteuant  dans  leur  interieur  des  masses  de  protoplasme.  La  reproduction,  comme 
je  l’ai  maintes  fois  surprise,  s’opfere  (il  me  semble)  par  la  rupture  de  la  membrane 
d’enveloppe.  Le  dechirement  de  chaque  cellule  peut  avoir  lieu  sur  un  seul  point, 
simulant  nn  bourgeonnemeut,  mais  presque  toujours  la  membrane  d’enveloppe  se 
rompt  en  divers  points  d’une  manifere  irreguliere,  et  sur  les  lambeaux  resultant  de  ce 
dechirement  on  note  des  amas  pigmentaires  visqueux,  auxquels  adhferent  les  cellules- 
germes.*  Celles-ci  se  fixant  sur  les  debris  des  cellules  detruites  se  groupent  trfes-souvent 
d’une  manifere  plus  ou  moins  symetrique,  tantot  sous  la  forme  de  poire,  tantot  sous  la 
forme  de  pommes  de  pin  ou  d’oranos,  tantot  sous  la  forme  de  longs  chapelets  plus  on 
moins  flexueux.  La  grandeur  de  ces  microorgauismes  n’est  que  d’un  millifeme  de  mil- 
limetre it  un  millieme  et  demi  de  millimetre. 

Chaque  cellule  adulte  au  moment  de  proliferer  laisse  echapper  en  dehors  deux  pig- 
ments differents,  l’un  jaune,  destine  it  s’infiltrer  dans  tous  les  tissus  et  it  produire  la 
couleur  ict6rique  qui  a donne  le  nom  it  la  maladies,  l’autre,  noir,  qui  est  insoluble  et 
destine  it  etre  entraine  dans  le  couraut  circulatoire,  produisant  soit  des  obstructions 
capillaires,  soit  des  stases  sanguines  dans  le  parenchyme  des  organes.  L’ouvrie  est 
occasionnee,  ou  moins  en  graud-partie,  ainsi  que  le  demontre  l’examen  microscopique, 
par  l’agglomeration  des  microbes  et  leurs  debris  dans  l’interieur  des  canalicules  uri- 
naires,  y provoquant  par  leur  sejour  la  degenerescence  colloide,  qui  transformerait 
chaque  tube  uriniffere  dans  un  cordon  sans  cavite,  il  empecherait  ainsi  la  filtration 
renale.  La  mat i fere  noire  du  vomissement  est  due  it  ce  pigment.  Ceci  a paru  etrange 
dans  le  commencement.  Mais,  aprfes  la  publication  de  mes  premiferes  recherches,  on 
s’est  assure  qu’il  existe  dans  la  nature  un  grand  nombre  de  microbes  qu’on  a appeles 
chromogdnes,  et  qui  jouissent  de  la  propriete  de  fabriquer  des  pigments  dont  la  nuance 
est  variable,  quelquefois  des  matiferes  colorantes  d’une  couleur  eclatante.  Citons  it 
l’appui  de  ce  que  je  dis,  le  pigment  bleu  fouce  fabrique  par  le  bacillus  cyanogemis  et  la 
belle  teinte  rouge  paupre  que  nous  offre  le  microcogue  prodigiosus  et  le  microcogue  indi- 
cus.  D’ailleurs  la  presence  de  ces  pigments  a fete  constatfee  par  beaucoup  de  mfedecins, 
parmi  lesquels  je  citerai  les  Drs.  Rebourgeon,  Issartier  et  le  Prof.  Artigalas,  de  Bor- 
deaux. 

Mr.  le  Professeur  Cornil,  dans  son  Traiti  sur  les  BacUries  m’a  reproclife  d’avoir  repre- 
sente dans  les  dessins  de  mon  livre  Doctrine  Microbienne  de  la  Fievre  Jaune , des  masses 
de  pigment,  vu  que,  detail,  ces  pigments  sont  des  corpuscles  accidentels  et  non  des 
bacteries.  Je  sais  bien  que  ce  sont  des  corps  accidentels,  mais  ce  qu’il  ne  faut  pas  per- 
dre  de  vue  c’est  que  ces  corpuscles  accidentels  sont  correlatifs  avec  la  vie  du  microbe 
amaril  convaincu  de  ce  que  l’observateur  n’a  pas  le  droit  de  corriger  la  nature  et  de 
supprimer  ce  qu’elle  nous  prfesente  d’une  manifere  frappante,  j’ai  cru  de  mon  devoir  de 


* Je  donne  le  nom  de  spore  a ces  cellules-germes.  Meme  donne  que  les  microcoques  ne  puis- 
sent  se  reproduire  que  par  bourgeonnement,  chaque  bourgeon  formant  une  petite  cellule  commen- 
Vante  ne  serait  en  rigueur  qu’une  spore.  Je  ne  vois  pas  l’utilite  de  creer  de  ces  distinctives  sub- 
tiles, qui  ne  faut  qu’encombrer  la  science  do  noms  qui  ne  signifient  rien  d’essentiel. 


480 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


conserver  dans  mes  dessins  les  pigments  rencontres  dans  les  cultures,  d’autant  plus  que 
les  memes  pigments  jouent  un  role  tres  important  dans  la  pathogenie  de  la  maladie, 
les  deux  phenomenes,  ictcre  et  vomissement  noir,  etant  l’expression  symptomatique  de 
leur  presence  dans  l’organisme  des  malades.  Mr.  le  Prof.  Cornil  lui-meme  n’a  pas 
meconnu  le  grand  interet  qu’on  doit  attacher  a ces  matieres  pigmentaires,  car  il  s’y 
rapporte  plusieurs  fois  dans  son  Traits  dejit  cite.  Ainsi,  il  s’y  exprime  dans  les  tenues 
suivants,  it  la  page  522  : “Les  cellules  hepaliques  sont  turnefiees,  remplis  de  gouttes  de 
graisse  formant  une  couronne  autour  du  noyau  ; elles  continuent  des  grains  de  pigment 
jaune.  Les  contours  des  cellules  montrent  sou  vent  des  depressions  remplies  de  pigment.'" 

A la  page  528  le  meme  auteur,  se  rapportant  it  l’examen  du  rein  d’un  individu  mort 
de  fifevre  jaune,  nous  dit:  “ Parfois  ces  cellules  renferment  des  grains  de  pigment  jaune."  > 
A la  page  529  nous  trouvons  encore  les  mots  suivants  : “ Dans  le  conteuu  de  l’intestin 
nous  avons  trouve  dans  deux  cas  des  amas  denses  de  grands  microbes  ronds,  de  1 g 
environ,  6negaux,  aupres  desquels  il  existait  toujours  du  pigment  jaune  ou  brun." 

Mr.  le  Professeur  Cornil  a done  verifie  plusieurs  fois  les  pigments  que  je  represente 
dans  mes  dessins.  Je  suis  heureux  de  pouvoir  dire  qu’il  a constate  egalement  la  pre-  | 
sence  du  microbe  amaril  dans  des  organes  remis  du  Bresil.  Lorsque  j ’ai  ete  a Paris,  il 
y a quatre  mois  environ,  j’ai  eu  l’honneur  de  recevoir  la  visite  de  cet  illustre  savant 
dans  le  laboratoire  de  pathologie  comparee  du  Museum  d’Histoire  Naturelle,  od  je  fai- 
sais  mes  recberches  en  collaboration  avec  les  Drs.  Gibier  et  Rebourgeon.  Nous  avons 
eu  l’occasion  de  lui  presenter  les  cultures  sur  les  milieux  liquides  et  solides,  d’apres  les 
methodes  Pasteur  et  Kocb  et  de  le  satisfaire,  quant  it  l’exigence  de  coloration,  qu’il 
m’avait  reproche  dans  son  Traitd  de  ne  pas  avoir  fait.  Dans  cette  occasion  il  a pu  com- 
parer le  microbe  il  l’etat  frais  qu’il  n’avait  pas  encore  vu  avec  le  microbe  mort  et  teinte 
avec  le  chlorhydrate  de  rosaniline. 

Je  profite  cette  occasion  pour  lui  remercier  de  l’attention  qu’il  a pretee  it  mes  re- 
cherches,  ainsi  que  des  encouragements  et  de  la  bienveillance  avec  lesquelles  il  m’a 
accueilli.  Le  microbe  que  je  lui  ai  montre  avait  exactement  la  meme  forme  et  la  meme 
grandeur  que  celui  qu’il  avait  decrit  dans  son  Traite  sur  les  Bacteries,  ainsi  que  vous  J 
pouvez  constater  vous-meme,  Messieurs,  en  comparant  le  dessin  du  livrede  Cornil  (page 
523),  que  j’ai  l’honneur  de  vous  presenter,  avec  le  microbe  que  je  vous  montrerai  tout- 
a-l’heure,  sur  les  plaques  prepares  it  Paris  meme  et  au  Bresil  pendant  que  j’ai  travaille 
avec  le  Dr.  Sternberg. 

Passons  maintenant,  Messieurs,  it  dire  quelques  mots  sur  la  culture  du  microbe 
xanthogenique.  J’ai  fait  des  cultures  avec  le  succfes  le  plus  complet  dans  du  bouillon 
du  bceuf,  du  lait  et  les  solutions  du  gelatine.  Je  pref&re  faire  les  solutions  du  gelatine 
non  avec  de  l’eau  distillee,  mais  bien  de  l’eau  commune,  parce  que  cette  derniere  cou- 
tient  differents  sels  numeraux  et  meme  quelque  matiere  organique  utile  au  microbe. 
Vous  pouvez  trouver  tous  les  details  sur  la  pratique  des  cultures  que  j’ai  faites  dans  la 
premiere  partie,  (ebapitre  ill),  de  mon  rapport  Doctrine  Microbienne  de  la  Fievre  Jaune 
et  ses  Inoculations  Preventives  publie  a Rio  Janeiro  en  1885. 

Outre  la  methode  Pasteur  pour  la  culture  des  microbes,  j’ai  applique  aussi  mon 
microbe  la  methode  de  Koch  sur  les  milieux  solides. 

L’experience  m’a  demontre  que  la  microbe  amaril  se  colore  facilement,  bien  plus 
facilement  meme  que  beaucoup  d’autres,  au  moyen  des  couleurs  d’aniline,  telles  que 
le  chlorhydrate  de  rosaniline,  le  violet  rue  thy  le,  et  le  brun  Bismarck.  Dans  la  note  que 
nous  avons  presentee,  il  y a quelques  mois,  it  l’Academie  des  Sciences,  nous  avons 
signale  ce  fait,  et  Mr.  les  Drs.  Gibier  et  Rebourgeon  out  bien  voulu  moutrer  dans  la 
salle  des  Pas-Perdus,  it  beaucoup  de  persounes,  parmi  lesquels,  plusieurs  savants  mem- 
bres  de  l’lnstitut,  les  colonies  du  microbe  xanthogenique  teint6  eu  violet,  et  parfaite- 
ment  visible,  au  moyeu  d’uu  microscope  Verick,  oculaire  No.  3 et  objeetif  it  immersion 
homogene. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  481 


Eu  outre,  uous  avons  pu  cultiver  le  meme  micro-organisme  d’apres  la  methode  de 
Koch.  Transplants  dans  des  tubes  contenant  de  la  gelatine,  qu’on  perfore  an  moyeu 
d’un  lil  de  platine  sterilise  d’avance  et  charge  d’uue  petite  goutte  de  culture,  le  micro- 
organisme,  mainteuu  dans  l’etuve  a uue  temperature  de  15  25  degrSs,  se  developpc  en 

colonies  qui  prennent  la  forme  d’uu  clou,  dont  la  tete  serait  a la  surface  et  la  pointe  eu 
dessous,  enfoucSe  dans  la  gelatine.  Celle-ci  se  liquefie  peu-a-peu,  d’une  maniere  irre- 
guliere,  et  la  liquefaction  commence  toujours  sur  les  couches  superficielles;  ce  qui  denote 
que  le  microbe  en  question  est  aerobic. 

Pour  terminer  ce  que  j’ai  it  vous  dire  sur  revolution  du  microbe  amaril,  je  vous 
dirai  qu’il  jouit  de  la  propriety  d’elaborer  des  produits  appurtenant  il  la  classe  des  pto- 
maines (leucoma'ines  de  Gautier),  aux  depars  des  matieres  albumino'ides  et  autres  dont 
ils  se  nourriseut. 

Ces  ptomaines  sont  tries  toxiques  ; j’ai  fait  avec  elles  de  nombreuses  experiences  sur 
des  chiens  et  des  grenouilles,  experiences  qui  m’auraient  demontre  que  ces  alcalo'ides 
exercent  uue  influence  remarquable  sur  le  nerf  grand  sympathique  et  sur  les  nerfs 
pneumo-gastriques.  Plusieurs  symptomes  de  la  fifevre  jaune  s’expliqueraient  plausible- 
ment  ainsi,  en  vertu  des  desordres  profonds  imprimes  par  ces  poisons  dans  le  systeme 
cardiaque  et  dans  l’innervation  vaso-motrice. 

Daus  les  cultures  elles-memes,  il  se  forme  de  ces  ptomaines;  et  la  preuve  eu  est,  que 
si  I’on  fait  l’ensemenceiuent  du  microbe  daus  la  gelatine,  neutre  aux  papiers  reactifs, 
an  bout  de  quelques  jours  cette  gelatine  mauifestera  une  reaction  franchement  alcaline. 
D’ailleurs,  au  moyeu  des  precedes  conuus,  on  peut  extrain  de  ces  cultures  des 
ptomaines  semblables  il  celles  qui  se  forment  dans  l’interieur  de  l’organisme  atteint 
de  ha  fievre  jaune. 

2°  INOCULABILITE  DU  MICROBE  AMARIL.  SOM  ATTENUATION. 

J’ai  fait  un  grand  nombre  d’experiences  d’inoculation  chez  les  animaux,  afin  de 
constater  la  transmissibilite  de  la  maladie.  J’ai  remarque  le  suivant : que  non  seule- 
ment  les  inoculations  faites  directement  avec  du  sang  et  des  cultures  virulentes,  tuent 
les  lapins  et  les  cochons  d’lnde,  dans  l’espace  de  deux  il  dix  jours,  mais  encore  le 
sejour  de  ces  animaux  dans  une  atmosphere  plus  ou  moins  saturee  de  microbes  donne 
le  meme  resultat ; plusieurs  de  ces  animaux  moururent  simplement  pour  avoir  respire 
Pair  du  laboratoire  oil  je  faisais  mes  experiences  et  mes  autopsies  ; les  organes  de  ces 
animaux  presentaient  de  nombreux  microbes  specifiques.  J’ai  mis  hors  de  doute  l’ino- 
culabilite  du  microbe  par  des  injections  hypodermiques,  intra-veineuses  et  intra-visce- 
rales  ; j’ai  fait  plusieurs  series  d’experiences,  lesquelles,  je  suis  heureux  de  vous  l’an- 
noncer  ici,  out  ete  pleinement  constatees  recemment  par  Mr.  le  Dr.  Range,  medecin 
de  premiere  classe  de  la  marine  Franchise  aux  iles  du  Salut,  (Guyane  Framjaise).  Le 
coinpte  rendu  de  ces  experiences  a ete  publie  dans  les  Archives  de  Medecine  Navale  de 
l’annee  derni^re. 

La  transmission  de  la  fiitvre  jaune  effectuee  d’individu  a individu  avec  un  sang  pri- 
mitivement  virulent  et  dont  la  virulence  ne  perd  pas  de  sou  energie,  malgre  son  pas- 
sage il  travers  differents  organismes,  met  ainsi  en  6vidence  que  l’agent  producteur  de  la 
maladie  n’est  pas  mort,  mais  vivant  et  susceptible  de  reproduction  pas  transmis- 
sions successives.  Cet  agent  ne  peut  pas  etre  autre  chose  que  l’uuique  61eineut  anor- 
mal  figure,  que  l’on  rencontre  constamment  et  infailliblement  daus  tous  les  cas  prouves 
de  fievre  jaune,  c’est-ii-dire  le  micrococcus  xanthogenicus. 

Ces  preuves  directes  ayant  mis  hors  de  doute  la  nature  parasitaire  et  coutagieuse  de 
la  fifevre  jaune,  je  me  suis  applique  il  attenuer  le  microbe,  afin  de  le  transformer  dans 
un  produit  vaccinal. 

On  sait  que  la  fievre  jaune,  it  de  tres  rares  exceptions  pres,  attaque  une  seule  fois  le 
meme  individu  ; ce  caractkreest  propre  il  presque  toutes  les  maladies  trausmissibles  de 
Vol.  IV— 31 


482 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


nature  viruleute.  Si  on  arrive  pourtant  it  att6nuer  les  cultures  du  microbe  xanthoge- 
nique  de  sorte  it  ce  qu’elles  produisent  doucement  des  perturbations  fonctionnelles  et 
des  changements  de  composition  dans  le  sang  et  dans  les  tissus,  propres  a conferer  l'im- 
muuite,  nous  aurons  obteuu  pour  la  fiiivre  jaune  le  meme  grand  desideratum  obtenu 
pour  la  variole,  comme  pour  le  cholera  des  poules  et  pour  le  charbon  chez  les  animaux 
qui  possfedent  la  recepti  vite  pour  ces  maladies. 

Or,  j’ai  remarque  qu’au  bout  d’un  certain  nombre  de  cultures  successives  le  microbe 
produit  une  grande  partie  de  sa  virulence  et  pouvait  etre  inoculees  chez  les  cobages  sans 
produire  la  mort.  Ces  animaux  resistent  une  injection  de  50  centigrammes  ou  uu 
gramme  du  liquide  de  culture  attenuee;  iLs  presentent  une  legfere  fifevre,  de  l’amaigris- 
sement  et  quelques  autres  symptomes  qui  se  dissipent  au  bout  de  peu  de  jours.  En 
outre,  sur  uu  grand  nombre  d ’animaux  ainsi  vaccines,  ayant  fait,  quelques  jours  apres, 
une  injection  de  sang  virulent,  j’ai  constate  qu’aucun  d’eux  ne  mourait,  tandis  que  la 
meme  injection  tuait  tous  ceux  qui  n’avaient  pas  ete  inocules  avec  les  cultures  atte- 
nu6es. 

Voici  de  quelle  maniere  on  prepare  le  vaccin  : Ou  injecte  le  sang  d’un  malade  mort 
ou  sur  le  point  de  mourir  de  fi^vre  jaune,  dans  les  veins  d’un  cochon  d’Inde  ou  d’un 
lapin  ; puis,  le  sang  de  ce  premier  animal  est  inocule  dans  le  sang  du  second  de  la 
meme  esp&ce  et  ainsi  de  suite  jusqu’au  sixieme  ou  septifeme  animal.  Avec  le  sang  de 
ce  dernier,  on  fait  des  cultures  qu’on  trausplantera  quatre  fois  au  moins;  c’est  alors  que 
je  commence  a les  inoculer  it  l’homme,  non  sans  avoir  prealablement  verifie  sur  les  ani- 
maux, si  ces  inoculations  n’etaient  pas  susceptibles  de  produire  des  accidents  d’une  cer- 
taine  gravite. 

Ou  obtient  ainsi  une  dixifeme  ou  douzi&me  generation  du  microbe  primitif,  dont  la 
virulence  est  notablement  amoiudrie.  L’atteuuation  est  dde  aux  nouveaux  milieux 
que  le  microbe  traverse  en  passant  par  l’organisme  du  cochon  d’Inde,  et  en  etant 
cnltive  ensuite  dans  des  ballons  sterilises  contenant  du  bouillon  de  bceuf  ou  de  la 
gelatine. 

Du  reste,  les  cultures  s’attenuent  d’elles  rnenies  it  la  longue  sous  l’influence  del’air, 
au  point  qu’un  liquide  primitivement  virulent  peut  etre  inocul6  sans  danger  sept  ou 
dix  jours  aprfes. 

Ces  cultures  une  fois  attenuees  conserveut  indefiuiment  cette  attenuation  j usque  et 
pendant  les  saisous  epidemiques  durant  lesquelles  leur  activite  augmente  presque  in- 
sensiblement. 

Cependant,  j’ai  precede  it  des  experiences  qui  m’ont  conduit  i\  la  regeneration  de  la 
virulence  de  ces  cultures  ; et  je  puis  maintenaut  it  toute  6poque  de  l’aunee  durant  et 
en  dehors  de  la  periode  epidemique,  perpetuer  la  virulence  des  cultures  et  les  faire  pas- 
ser, it  ma  volonte,  de  l’etat  toxique  it  l’etat  att6nue  et  vice-versa,  les  soumettons  gra- 
duellement  it  l’energie  n6cessaire  it  la  vaccination  et  jusqu’a  l’activite  infailliblement 
mortelle. 

Yoici  comment  j’ai  precede  pour  l’obtention  de  cet  important  desideratum. 

1°  J’ai  pratique  l’inoculation  par  la  methode  hypodermique,  en  faisant,  sous  l’aile 
de  pigeons  ou  de  poules,  une  injection  d’un  gramme  de  culture  attenu6e  qui  m’a  servi 
pour  les  inoculations  sur  l’espfece  liumaine. 

2°  Trois  heures  aprfes,  j’ai  sacrifie  les  volatiles  dans  le  sang  desquels  la  culture  avait 
ete  it  l’etat  d’iucubation  ou  de  digestion,  recueillant  ce  sang  dans  des  ballons  sterilises  ; 
operation  it  laquelle  j’ai  precede  avec  toutes  les  precautions  techniques  necessaires  pour 
empeclier  l’introduction  de  germes  etrangers  dans  les  ballons. 

3°  Immediatement  apr^s,  j’ai  inocule  ce  sang  it  de  petits  oiseaux  dans  une  propor- 
tion e.gale  it  0.3  de  centimetre  cube  pour  30  grammes  du  poids  des  animaux. 

Tous  ceux  qui  out  servi  it  cette  experience  out  succombe  dans  uu  espace  de  uu  it  sept 
jours. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  483 


L’expArience  repetee  quinze  ibis  sur  des  Ms  et  des  sanhassus*  a fourni  des  rAsultats 
identiques. 

4°  L’autopsie  pratiquAe,  j’ai  trouvA  dans  le  corps  des  oiseaux  des  lesions  semblables 
A celles  produites  par  la  fiAvre  jaune  et  entre  ces  signes,  ,je  citerai,  comme  Atant  d’une 
haute  importance  diaguostique  la  matiere  noire  couleur  d’encre  a,  derive  rencontree  dans 
le  gesier  et  dans  les  intestins. 

Le  sang  de  ces  oiseaux,  examine  au  microscope  montrait  les  microbes  caracteristiques 
de  la  maladie. 

5°  Le  sang  des  poules  et  des  pigeons  sacrifiAs,  d’apres  ce  que  j ’ai  dit  au  paragrapbe 
2°,  a conserve  la  virulence  mortif  Are  durant  16  jours  aprAs  lesquels  1’attAnuation  s’est 
declaree. 

6°  Le  meme  sang  inoculA  A des  cocbons  d’Inde  (cobaye)  (inoculation  intra  hepatique, 
dans  le  peritoine  ou  simplement  sous-cutanAe)  et  ce  dans  la  proportion  de  0.5  de  cen- 
timetre cube  pour  500  grammes  du  poids  de  1 ’animal  a manifeste  Agalement  la  propriete 
toxique,  tuant  les  sujets  dans  un  espace  qui  a varie  entre  deux,  trois,  sept  et  dix  jours. 

Les  lesions  auatomiques  confirmerent  le  diagnostic  de  la  fiAvre  jaune  ; le  liquide 
rencontre  dans  l’estomac  Atait  tres  obscur  et  noir  et  les  urines  contenaient  de  l’albu- 
mine. 

7°  Si  on  injecte  le  sang  du  pigeon  ou  de  la  poule  No.  1 A un  de  leurs  congAnAres  Nos. 
2,  3,  4 ou  5,  on  remarque  que  l’Auergie  du  virus  diminue  progressivement  a mesure  que 
s’AlAve  le  nombre  des  transplantations  faites  successivement  d’un  animal  A un  autre. 
Ou  peut  done  ainsi  se  procurer  constamment  une  sArie  de  cultures  systAmatiquement 
graduAes. 

8°  Les  cultures  attenuees  inoculAes  A des  animaux  (oiseaux  ou  cochons  d’Inde)  lenr 
confArent  1’immunitA  de  la  vaccination,  les  rendant  refractaires  A Faction  du  virus 
mortif  Are. 

9°  On  trouve  dans  tous  les  cas,  dans  les  cultures  graduees  ainsi,  le  microbe  spAci- 
fique  avec  les  caracteres  ordinaires. 

10°  Me  bornant,  quant  A present,  A la  description  de  ces  faits,  je  n’entrerai  pas, 
pour  le  moment,  dans  la  question  de  la  theorie  interpretative  applicable  A cette  reap- 
parition de  la  virulence  des  cultures  par  le  fait  de  sa  simple  permanence  durant  quel- 
ques  heures  dans  l’interieur  d’un  organisme  animal  refractaire  lui-meme  A la  fiAvre 
jaune  et  ce,  d’accord  avec  ce  que  demontrent  mes  observations  decrites  dans  mon  der- 
nier ouvrage  re  repetees  recemment,  avec  un  resultat  identique  par  le  Dr.  Range,  me- 
deein  de  la  marine  fran9aise. 

Le  fait  d’un  organisme  se  refusant  A un  etat  morbide  determine  et  pouvant  aider  A 
la  virulence  de  cet  etat  morbide  pourra,  quelque  extraordinaire  que  cela  paraisse,  nous 
fournir  l’explication  d’un  grand  nombre  de  questions  relatives  A des  particularites  de 
contagion  durant  les  epidbmies,  comme  il  se  pretera  aussi  A expliquer  bien  des  circons- 
tances  obscures  concernant  l’heredite  de  diverses  affections. 

3°  VACCINATION'  PRATIQUEES  CHEZ  L’HOMME.  SES  R^SULTATS  PRATIQUES. 

C’est  seulement  aprAs  les  longues  expAriences  dejA  dAcrites,  sur  le  pouvoir  virulent 
du  microbe  de  la  fiAvre  jaune,  que  je  me  suis  encouragA  A l’inoculer  dans  l’organisme 
humain. 

Les  premiers  400  vaccinations  furent  faites  par  la  mAthode  endermique,  mais  eu- 
suites  j’ai  adoptA  de  prAfArence,  la  mAthode  hypodermique  beaucoup  plus  sOre  et  plus 
pratique. 

On  procAde  de  la  maniAre  suivante  : Les  cultures  sont  tirAes  des  ballons  avec  tout 


* On  donne  ces  noms  A des  oiseaux  appartenant  au  genre  tanarjra,  et  qui  se  nourissent  d’or- 
ganes,  do  bananes  et  d’autres  fruits. 


484 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


le  soin  necessaire  pour  6viter  l’entree  de  gerraes  Strangers  et  conservees  dans  dc  petits 
flacons  de  quatre  a huit  grammes  prealablement  sterilises  par  la  ehaleur  et  bouehes  ;i 
l’emeri.  Dans  une  seringue  Pravaz  on  recueille  quelques  gouttes  du  liquide  prealable- 
ment vers6  dans  une  capsule  bien  propre  et  on  en  introduit  ensuite  sous  la  peau  une 
quantit6  variant  d’un  dixieme  de  centimetre  cube  a un  centimetre  cube,  selou  Page  de 
l’individu. 

Les  troubles  consecutifs  a la  vaccination  rappellent  les  prodromes  de  la  fievre  jaune  ; 
ils  se  traduisent  par  de  la  cephalalgie  intra-orbitaire,  des  frissons,  une  lassitude  gene- 
rale  avec  pesanteur  des  jambes,  rachialgie,  reaction  febrile  (37.5°,  38.39°  centig. ) 
legdre  barre  dpigastrique  et  quelquefois  des  nausees  et  meme  des  vomissements,  le  tout 
ne  se  prolongeant  pas  au  del de  deux  ou  trois  jours,  sans  l’intervention  d’aucune 
medication.  Localement  il  n’y  a rien  qui  puisse  expliquer  ces  phenomdnes,  car  il  se 
produit  a peine  autour  des  frigdres  une  legere  areole  rouge,  qui  se  dissipe  prompte- 
ment. 

Je  vais  vous  donner  le  resume  des  resultats  obtenus  jusqu’ici  au  moyen  de  la  pra- 
tique de  ces  vaccinations,  lesquelles  sont  pratiques  gratuitement  et  ont  ete  autorisees 
par  l’arrete  ministeriel  du  gouvernement  Bresilieu  No.  4546  du  9 Novcmbre,  1883. 

Pendant  l’epidemie  de  fievre  jaune  qui  a reigne  a Rio  Janeiro  1883-1884,  j’ai  vac- 
cine 418  personnes,  non  seulement  avant  l’epidemie,  mais  pendant  que  celle-ci  etait 
dans  sa  plus  grande  intensite. 

Le  nombre  des  personnes  non-vaccinees  mortes  de  la  fievre  jaune  s’est  eieve  ii  650. 
Parmi  les  personnes  vaccinees,  il  en  est  sept  qui  figurent  egalement  sur  la  liste  des  deces 
comme  etant  mortes  de  la  maladie.  Bien  qu’il  reste  des  doutes  serieux  au  sujet  de  ce 
diagnostic,  je  suivrai  le  conseil  de  mon  distingue  confrere  le  docteur  Trouessart  : je  ne 
chercherai  pas  it  dissimuler  ces  quelques  rares  insucces,  surtout  en  face  du  chiffre  itnpo- 
saut  de  vaccinations  heureuses  (411),  que  j’ai  le  droit  de  porter  it  mon  actif.  Ce  chiffre 
de  sept  deces  donue  une  proportion  excessivement  favorable,  surtout  si  l’on  rdfldchife 
que  les  malades  en  question  appartenaient  it  la  classe  ouvriere  et  habitaient  des  estala- 
gcns,  chambres  etroites,  liumides  et  mat  aerees,  dans  le  quartier  le  plus  malsain  de  la. 
ville,  oil  la  mortalite  a ete  considerable  parmi  les  personnes  non-vaccinees,  et  surtout 
les  ouvriers  etrangers.  Sur  les  650  personnes  non-vaccinees  mortes  de  la  fievre  jaune 
(d’Octobre  1833  it  Juin  1884),  577  etaient  des  etrangers,  73  seulement  etaieut  des  Bre- 
siliens.  Or,  j’ai  vaccine  307  etrangers  ; les  Bresilieus  qui  compl&tent  le  chiffre  de  418 
venaieut  tous  de  l’interieur  et  se  trouvaient.  par  consequent,  dans  les  memes  conditions 
de  receptivite  que  les  Strangers,  la  fievre  jaune  etant  inconnue  dans  l’intdrieur  du  Bre- 
sil  et  ne  sevissant  que  sur  le  littoral  maritime.  Aucuu  des  Bresilieus  vaccines  n’est 
mort  de  la  fievre  jaune. 

Les  resultats  obtenus  l’annee  suivaute  (de  Janvier  ii  Aofit  1885),  it  l’aide  d’inocula- 
tions  faites,  non  plus  it  la  lancette  comme  les  prdcddentes,  mais  par  la  methode  hypo- 
dermique,  sont  encore  plus  favorables.  Dans  cette  intervalle,  le  nombre  des  deces  de 
fievre  jaune  parmi  les  personnes  non-vaccinees,  it  Rio  de  Janeiro,  s’est  eieve  it  278,  dont 
200  dtrangers  et  78  Bresiliens,  sur  lesquels  44  seulement  dtaient  nes  dans  cette  ville. 
Aucuu  d’eux  n’avait  dte  vaccine.  Dans  cette  meme  periode,  j’ai  vaccine  3051  per- 
sonnes, dont  2186  nationaux  et  865  etrangers.  Sur  les  2186  nationaux,  625  dtaient  des 
enfants  en  bas-age  issus  d’etrangers,  et  par  consequent  aussi  receptibles  que  les  etrau- 
gers  eux-memes.  Pendant  toute  la  duree  de  l’dpiddmie,  pas  un  seul  n’avait  succombe. 
L’immunitd  a done  etc  absolue. 

Ces  chiffres  parleut  d’eux-memes,  je  crois.  Eh  bien!  ce  n’est  pas  tout;  car  pendant 
la  deruikre  Epidemic,  qui  a sevi  it  Rio  en  1886,  les  resultats  statistiques  sont  venus  con- 
firmer leur  Eloquence. 

En  effet,  pendant  cette  periode,  nous  avons  vaccind  3473  personnes,  aiusi  re  parties  : 
Brdsiliens  2763,  dtrangers  710.  Parmi  les  2763  Brdsiliens,  on  rencontre  489  fils  d’etrau- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


485 


gers,  tons  tres  jeunes,  et  qui  en  realite  peuvent  se  rattacher  aux  710  etrangers,  comme 
present-ant  le  me  me  degre  de  receptivite  que  ces  deruiers.  De  pins,  222  provenaient 
de  diffe rentes  provinces  de  l’interieur  et  du  midi,  c’est-ii-dire  dans  des  conditions  tres- 
favorables  pour  contracter  la  maladie.  C’est  done  en  realite  a 1421  vaccines  qu’il  faut 
porter  le  nombre  de  ceux  pour  lesquels  le  sejour  ne  pent  etre  invoque  comme  cause 
d’immunite  contre  la  contagion.  Restent  2053  sujets  Bresiliens,  dont  l’age  varie  de 
quelques  mois  a 60  ans.  Dans  ce  groupe,  un  grand  nombre,  par  leur  age,  leur  condition 
d’habitation  dans  les  quartiers  de  la  ville  les  plus  eprouves  par  le  fleau,  se  trouvaient 
dans  les  conditions  les  plus  favorables  pour  en  devenir  victimes.  Parmi  les  personnes 
vaccinees,  il  n’y  a eu  que  liuit  decedes  de  fifevre  jaune  ; une  desquels  avait  et6  inoculee 
en  1885,  tandis  que  dans  le  meme  espace  de  temps  la  mortalite  par  la  meme  maladie 
parmi  les  personnes  non-vaccin&s  a ete  de  1389,  ainsi  reparties  : etrangers  1079,  Bre- 
siliens 310. 

Si  nous  faisons  le  resume  general  des  vaccinations  pratiquees  par  la  metbode  liypo- 
dermique,  pendant  les  6pidemies  de  1885  et  1886,  nous  trouverons  le  resultat  sui- 


vant  : — 

1°  Vaccinations  pratiquees  en  1886 3473 

Morts  vaccines 7 

2°  Vaccinations  pratiquees  en  1885 3051 

Mort  vaccine 1 

Total  des  vaccines 6524 

Total  des  morts  vaccines 8 

Mortalite  des  morts  vaccines 0.1  p.  c. 


Mortalite  des  non- vaccines,  d’apres  les  chiffres  officiels,  et  dont  la  mort  est  due  lr- 
fievre  jaune,  pendant  les  annees  1885  et  1886  : 1667. 

Maintenant  faisons  le  calcul  de  maniere  a comprendre  egalement  la  statistique  de 
1884,  a l’epoque  oil  nous  employions  la  methode  endermique  ; nous  aurons  : — 


Vaccines 6942 

Morts  vaccines 15 


Ce  qui  donne  it  peine  0.2  p.  c.  pour  la  mortalite  des  vaccines. 

Morts  non-vaccines  : 2317. 

Jenevousoffre  id  qu’un  abrege  tres-court,  tous  les  details  statistiques  out  con- 
stitue  un  memoire  qui  a ete  presente  it  l’Academie  des  Sciences  de  Paris. 

Toutefois,  je  pense  que  c’est  bien  assez  pour  demontrer  les  bienfaits  reels  qui  pour- 
ront  resulter  de  la  generalisation  de  ce  moyen  prophylactique. 

Pour  tous  les  details  relatifs  aux  statistiques  je  vous  engage  de  lire  les  ouvrages  sui- 
vants  dont  j’ai  l’honneur  de  vous  offrir  quelques  exemplaires  : — 

1°  Rapport  sur  les  inoculations  preventives  de  la  fikvre  jaune  durant  l’epidemie  qui 
a r6gn<j  en  1883  et  1884,  it  Rio  de  Janeiro  et  presente  au  Ministre  de  l’interieur  au  Bre- 
sil,  ce  rapport  est  annexe  it  mon  ouvrage  “ Doctrine  Microbienne  de  la  Fievre  Jaune.” 

2°  Le  vaccin  de  la  fievre  jaune.  Resultats  statistiques  des  inoculations  preventives 
pratiquees  avec  la  culture  dn  microbe  attenue,  de  Janvier  it  Aofit  de  1885. 

3°  Statistique  des  vaccinations  pratiquees  avec  la  culture  attenuee  du  microbe  de  la 
fievre  jaune  de  Septembre  1885  it  Septembre  1886. 

Je  vous  recommanderais  encore  la  lecture  du  memoire  presente  par  les  Drs.  Rebour- 
geon, Gibier  et  moi  ii  l’Academie  des  Sciences  de  Paris,  et  intitule  : Resultats  obtenus 
par  l’inoculation  preventive  du  virus  attenue  de  la  fifcvre  jaune. 

Cette  note  a ete  presentee  et  lue  devant  l’Academie  des  Sciences  par  le  regrette  Prof. 
Vulpian,  qui  l’a  precedee  de  quelques  considerations  tres  flatteuses  pour  nous,  en  nous 
rendant  ainsi  un  service  considerable  pour  la  reussite  de  nos  recbercbes.  Je  dois  vous 
dire  que  le  Prof.  Vulpian  a bien  voulu  se  charger  de  prendre  un  grand  interet  pour  rues 
travaux,  apres  les  avoir  examines  minutieusement.  II  a non  seulement  analyse  lescul- 


486 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


tures  et  les  preparations  microscopiques,  mais  encore  les  livres  et  les  carnets  ou  je  fai- 
sais  inscrire  les  noms,  nationalites,  ages,  etc.  de  toutes  les  personnes  vaccinees.  Sa 
patience  est  alle  jusqu’au  point  de  lire  un  grand  nombre  de  petites  notes  recueillies  par 
mou  auxiliaire,  le  Dr.  Comiuhoe  Fils,  relatives  aux  symptomes  observes  dans  chaque 
individu  dans  les  trois  premiers  jours  suivant  la  vaccination.  J’ai  ete  tres  content  de 
cette  rigueur,  elle  a donn6  eu  resultat  une  forte  impulsion  communiquee  a ma  decou- 
verte  ; c’est  un  grand  service  que  je  dois  il  ce  grand  medecin  qui  vient  de  disparaitre  de 
la  scfcne  du  monde  scientifique,  comme  un  meteore  lumineux  qui  a plonge  majestueu- 
sement  dans  la  nuit  de  l’eternite. 

Je  terminerai  ma  communication,  Messieurs,  en  vous  presentant  nos  salutations  de 
remerciment,  et  en  vous  montrant  sous  le  microscope  plusieurs  preparations  du  microbe 
amaril  cultive  dans  l’agar  agar  peptonise  et  colore  par  le  chlorhydrate  de  rosaniline. 


After  the  reading  of  the  paper  of  Dr.  Domingos  Freire,  the  President,  Dr.  Jones, 
tendered  the  thanks  of  the  Section  for  the  energy  and  scientific  zeal  displayed  by 
Professor  Freire,  in  performing  a long  and  tedious  sea  voyage  from  Rio  de  Janeiro 
to  Washington  for  the  purpose  of  laying  the  results  of  his  investigations  and  experi- 
ments before  his  brethren  of  the  medical  profession  of  America  and  other  countries. 

The  President  had  invited  Professor  Carmona,  of  the  University  of  Mexico,  to 
be  present,  and  in  like  manner  unfold  his  method  of  1 ‘ inoculating  ” or  “ vaccinating ' ’ 
against  yellow  fever. 

Although  Professor  Carmona  had  accepted  his  invitation  in  a hearty  and  enthu- 
siastic manner,  he  had  not,  as  yet,  arrived  in  Washington. 

It  is  truly  remarkable  and  interesting  that  two  native-born  Americans,  with  the 
blood  of  its  ancient  inhabitants  coursing  through  their  veins,  should  have,  in  two 
widely  separated  countries  in  North  and  South  America,  boldly  attempted  to  settle 
one  of  the  most  important  problems — namely,  the  arrest,  prevention  or  modification 
of  yellow  fever  by  inoculation. 

In  order  to  apply  the  principles  established  by  the  immortal  Jenner  to  the  arrest 
or  modification  of  yellow  fever,  Dr.  Jones  had,  during  the  past  seventeen  years,  as 
opportunity  offered,  performed  experiments  on  living  animals  with  the  blood  and 
black  vomit  of  yellow  fever. 

The  animals  thus  experimented  on  in  1870,  1873  and  1878  universally  died,  in 
periods  ranging  from  12  to  72  hours,  and  the  blood  was  found  to  contain  numerous 
bacteria  and  micrococci.  Such  experiments  had  deterred  him  from  inoculating  the 
human  being;  and  as  there  has  been  no  epidemic  of  yellow  fever  in  New  Orleans 
since  the  year  1878,  he  regarded  his  experiments  as  incomplete. 

During  the  yellow  fever  epidemic  of  1878,  Dr.  Jones  conducted  an  elaborate 
series  of  experiments  on  the  atmosphere  of  infected  localities  and  houses  containing 
yellow  fever  patients.  The  method  consisted  essentially  in  passing  from  100,000  to 
400,000  cubic  feet  of  air  through  ice  in  fragments  and  through  ice-cold  water,  and 
then  subjecting  the  water  to  examination  with  the  higher  powers  of  the  microscope. 
As  the  results  of  the  seexperiments  have  been  recorded  in  the  New  Orleans  Medical  1 
and  Surgical  Journal  for  1879,  it  is  unnecessary  to  enter  into  a detailed  statement. 
The  following  facts,  however,  will  he  stated  as  bearing  on  the  paper  of  Dr.  Freire, 
now  under  consideration. 

1.  The  atmosphere  in  the  rural  and  badly  drained  and  unpaved  districts  presented 
microorganisms,  spores  and  vegetable  cells  differing  from  those  of  the  paved  districts. 

2.  In  the  well-paved  districts  he  had  found  in  the  air,  by  the  aid  of  the  high 
powers  of  the  microscope,  minute  spores,  microbes  and  micrococci,  varying  from  one 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


487 


ten-thousandth  to  one  twenty-thousandth  of  an  inch  in  diameter,  similar  to  some  of 
the  particles  found  in  the  blood  and  black  vomit  of  yellow  fever. 

3.  In  the  air  of  the  poorly  drained,  unpaved  and  malarious  portions  of  the  city 
of  New  Orleans  he  had,  on  the  contrary,  found  similar  microorganisms  to  those  which 
he  had  observed  in  the  blood  of  malarial  fever  patients. 

Iu  conclusion,  Dr.  Jones  said  that  he  had  hoped  that  those  persons  who  had  set 
up  claims  to  be  microscopists  and  wbo  had  attempted  to  decry  and  disparage  the  labors 
of  Professor  Domingos  Freire  would  have  the  manliness  to  meet  him  face  to  face 
iu  an  open  and  just  discussion  of  its  methods  and  results. 

Dr.  Jones  advocated  the  thorough  investigation  of  this  subject,  not  by  prejudiced 
partisans,  inexperienced  in  the  diagnosis  and  treatment  of  yellow  fever,  but  by  earnest, 
and  just,  and  experienced,  and  accomplished  observers,  supplied  with  such  liberal 
appropriations  by  their  respective  governments,  and  armed  with  all  the  chemical, 
philosophical  and  microscopical  reagents,  and  instruments  of  the  greatest  perfection, 
which  are  adapted  to  the  thorough  investigation  not  merely  of  the  subject  of  inocu- 
lation against  yellow  fever,  but  of  all  points  relative  to  the  origin  and  propagation 
of  this  disease,  to  its  nature,  history,  pathology  and  treatment. 

Dr.  Domingos  Freire  then  presented  to  the  Fifteenth  Section  numerous  microscop- 
ical specimens  of  the  yellow  fever  microbe.  Dr.  Y.  Id.  Lemonnier,  French  Secretary, 
translated  the  paper  of  Dr.  Freire  into  English.  The  President  requested  Dr.  Freire 
to  answer  such  questions  as  the  members  of  the  Fifteenth  Section  might  propound, 
and  Dr.  Felix  Formento,  of  New  Orleans,  Italian  Secretary,  acted  as  interpreter, 
as  Dr.  Freire  was  not  fully  conversant  with  the  English  language. 

The  following  is  a brief  outline  of  the  discussion  of  the  paper  of  Dr.  Freire  by 
the  officers,  Council  and  members  of  the  Section  on  Public  and  International  Hygiene. 

DISCUSSION. 

Upon  conclusion  of  the  reading  of  the  paper  and  translation,  Dr.  Felix  For- 
mento, of  New  Orleans,  Louisiana,  asked  Dr.  Freire  whether  he  adopts  the  Pasteur 
theory  of  the  attenuation  of  the  virus  by  oxidation. 

Dr.  Freire  replied  that  the  attenuation  is  due  to  two  causes,  viz. : 1st  oxidation 
through  the  red  corpuscles  of  the  blood,  and  2d,  to  the  fact  that  when  virus  is  trans- 
planted it  may  not  find  in  the  second  animal  the  same  soil  as  in  the  first,  and  it 
becomes  modified  ; but  all  this  is  as  yet  only  conjecture. 

To  inquiries  of  Dr.  Joseph  Jones,  regarding  the  exact  microscopic  appearance 
of  the  microbe,  its  size,  shape,  etc.,  and  what  it  forms  in  final  development,  and  its 
histological  structure,  Dr.  Freire  replied  that  its  histological  structure,  like  that  of 
other  microbes,  is  obscure.  It  is  of  a vegetable  nature  and  has  a cellular  form,  com- 
posed of  an  envelope  enclosing  a protoplasm.  He  assented  to  Dr.  Jones’  remark  that 
he  would  then  call  it  a micrococcus,  the  lowest  form,  and  referred  to  the  more  extended 
description  made  in  his  paper.  Its  diameter  is  one-thousandth  of  a millimetre,  and  its 
form  remains  the  same  in  the  virulent  and  attenuated  cultures. 

Dr.  Jones — “Have  you  ever  found  the  microbe  in  the  blood  of  a living  patient?” 

Dr.  Freire — “Yes,  in  all  cases  of  genuine  yellow  fever.” 

Dr.  M.  K.  Taylor,  United  States  Army,  inquired  whether  the  appearance  of 
the  microbe  of  yellow  fever  is  sufficiently  marked  to  enable  an  accomplished  micro- 
scopist  to  distinguish  it  from  a microbe  of  malaria. 


488 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Dr.  Freire  replied  that  several  different  microbes  of  malaria  have  been  described. 
Yet  all  of  them  are  very  different  from  the  microbe  of  yellow  fever,  and  the  charac- 
teristics of  the  yellow  fever  microbe  are  sufficiently  striking  to  enable  a microscopist 
to  distinguish  it. 

Dr.  P.  H.  Bailhache,  United  States  Marine  Hospital  Service,  inquired  whether 
the  vaccination  in  one  family  arrested  the  progress  of  the  fever  in  that  family. 

Dr.  Freire  answered  in  the  affirmative,  stating  that  his  vaccinations  were  made 
in  the  portions  of  the  city  where  the  disease  was  most  virulent,  and  that  in  families 
of  ten  or  fifteen  members,  living  in  a cite  ouvriere,  if  vaccination  was  practiced  after 
the  outbreak  of  the  fever,  among  the  members  not  yet  affected,  this  vaccination, 
in  a very  large  number  of  cases,  arrested  the  further  progress  of  the  disease  in  that 
family,  whereas  where  it  was  not  practiced,  they  all  were  stricken  down  with  the 
fever  and  many,  if  not  all,  died. 

Note. — Dr.  Freire  stood  on  the  platform  while  the  questions  were  asked  by  different  members 
of  the  Section.  Dr.  Felix  Formcnto  stood  at  his  side  and  translated  the  questions  into  French, 
and  translated  into  English  his  replies  as  made. 

The  following  resolution,  offered  by  Dr.  Felix  Formento,  of  New  Orleans,  was 
adopted : — 

Be  it  Resolved,  That  the  grateful  thanks  of  the  Fifteenth  Section,  Public  and  Inter- 
national Hygiene,  of  the  Ninth  International  Medical  Congress,  be  tendered  to 
Dr.  Domingos  Freire,  of  Brazil,  for  his  most  eloquent,  scientific  and  masterly  address, 
expounding  the  nature  of  a doctrine  the  practical  application  of  which  may,  to  a 
certain  degree,  cause  the  gradual  disappearance  of  one  of  the  most  fatal  diseases 
that  affect  mankind,  revolutionizing  the  social  and  political  condition  of  certain  por- 
tions of  the  world. 

Be  it  Resolved , That  the  Executive  Committee  of  the  Ninth  International  Medical 
Congress  be  earnestly  requested  to  publish  the  paper  of  Dr.  Freire  in  extenso  in  the 
Transactions  of  the  Congress. 

The  foregoing  resolutions  were  duly  transmitted  to  President  N.  S.  Davis,  of  the 
Ninth  International  Medical  Congress. 

Dr.  J.  McF.  Gaston,  of  Atlanta,  Georgia,  said  he  feared  that  anything  he  might 
say  would  detract  from  the  decidedly  favorable  impression  made  by  the  statistical 
report  presented  in  regard  to  the  protection  afforded  by  inoculation  of  the  cultured 
virus  of  yellow  fever.  But  it  turned  out  that  he  was  residing  in  Brazil  during  the 
early  investigation  of  this  subject  by  Dr.  Freire,  and  had  kept  abreast  of  all  that  he 
had  done  since  toward  a verification  of  the  prophylactic  virtues  of  yellow  fever. 
Shortly  after  his  return  from  Brazil,  in  1884,  he  undertook  to  enlist  the  attention  of 
the  officials  of  the  United  States  Government  in  behalf  of  an  investigation  of  the 
claims  of  yellow  fever  inoculation.  Communications  were  at  different  times  addressed 
to  the  Secretary  of  the  Treasury  and  to  President  Cleveland,  which  only  elicited 
responses  that  there  were  no  funds  set  apart  for  such  an  undertaking. 

Supposing  that  an  appeal  to  the  municipal  authorities  of  New  Orleans  might  be 
more  successful,  a letter  was  addressed  to  Dr.  Joseph  Holt,  President  of  the  Board 
of  Health,  setting  forth  what  had  been  accomplished  by  Dr.  Freire  in  Brazil,  and 
requesting  his  cooperation  in  securing  consideration  for  yellow  fever  inoculation. 
Fortunately,  about  the  same  time  he  had  received  a report  of  successful  inoculation 
from  a physician  in  Panama,  and  was  prompted,  by  his  own  convictions  of  the  import- 
ance of  the  method,  to  present  it  to  the  meetiug  of  the  American  Public  Health 
Association  at  the  city  of  Washington. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  489 

The  proposition  was  favorably  entertained,  and  the  result  was  shown  in  the  early 
drafting  of  a bill  providing  for  the  appointment  of  three  medical  men  as  commis- 
sioners and  the  appropriation  of  $30,000  to  investigate  the  claims  of  yellow  fever 
inoculation. 

Dr.  Holt  showed  great  energy  in  laying  this  before  Congress  ; but,  unfortunately, 
there  were  influences  at  work  against  the  measure,  from  New  Orleans,  and  every 
available  means  of  reaching  the  members  of  Congress  by  journals  and  circulars  were 
practiced  by  the  medical  men  connected  with  the  New  Orleans  Medical  and  Sur- 
gical Journal.  If  there  be  any  credit  connected  with  such  a proceeding  they  are 
entitled  to  its  benefits.  But  on  the  other  hand,  if  any  detriment  has  been  caused  to 
the  progress  of  a good  work,  they  must  be  held  responsible  at  the  tribunal  of  public 
opinion  for  this  untoward  result. 

While  this  bill  was  still  pending  before  Congress,  he  presented  a series  of  resolu- 
tions at  the  meeting  of  the  American  Medical  Association,  for  memorializing  the 
United  States  Congress  in  favor  of  its  adoption.  This  memorial,  setting  forth  what 
had  been  accomplished  by  Freire,  Carmona,  Finlay  and  others,  was  signed  by  him- 
self, as  chairman,  and  Dr.  R.  0.  Hooper,  of  Little  Rock,  Arkansas,  but  without  the 
name  of  the  third  member  of  the  committee,  Dr.  T.  G.  Richardson,  of  New  Orleans, 
who  excused  himself  from  signing  it,  on  account  of  opposition  to  the  measure. 

In  view  of  these  unfavorable  influences,  the  American  Congress  only  voted  an 
appropriation  of  $10,000  for  the  investigation,  which  involved  the  interests  of  vast 
portions  of  the  people  in  this  country,  and  the  President  appointed  but  one  com- 
missioner to  enter  upon  the  exploration  of  the  data  connected  with  yellow  fever 
inoculation  in  Mexico  and  Brazil.  Dr.  George  Sternberg,  of  the  Army  staff,  was 
assigned  to  this  duty,  and,  his  salary  being  already  provided  for,  it  was  doubtless  con- 
sidered that  the  small  appropriation  would  suffice  for  the  investigation. 

Unfortunately,  instead  of  proceeding  first  to  Mexico,  in  June  of  the  present  year, 
when  it  might  have  been  expected  that  yellow  fever  would  be  found  there,  as  it  falls 
within  the  Northern  hemisphere  and  has  summer  comparing  to  that  of  the  United 
States,  Dr.  Sternberg  was  ordered  to  Rio  de  J aneiro,  where  yellow  fever  was  not  likely 
to  occur,  being  the  winter  of  that  region  south  of  the  equator. 

It  is  likewise  to  be  noted  that  he  went  to  investigate  the  processes  of  Domingos 
Freire,  when  every  one  conversant  with  foreign  literature  should  have  known  that 
Freire  was  in  Paris,  for  the  purpose  of  laying  his  views  and  experiments  before  the 
Scientific  Academy  of  France.  He  thus  remained  in  Rio  de  Janeiro  for  a month,  in 
the  absence  of  Freire,  but  was,  perhaps,  able  to  turn  the  time  to  profitable  account 
in  verifying  the  statistics  which  had  been  published  previously,  under  the  authority 
of  the  Brazilian  Government.  After  the  return  of  Freire  to  Rio  de  Janeiro,  he  had 
an  opportunity  of  observing  his  processes  in  preparing  the  various  cultures  of  the 
micrococcus  discovered  previously  by  him,  but  there  was  no  occasion  for  testing  the 
application  of  this  inoculation  in  cases  of  yellow  fever. 

It  will  not  be  a matter  of  surprise,  therefore,  if  Dr.  Sternberg  has  returned  from 
his  sojourn  in  the  pleasant  winter  climate  of  Brazil  without  bringing  any  satisfactory 
information  touching  the  merits  of  inoculation  against  yellow  fever. 

The  Government  of  these  United  States  is,  of  course,  responsible  for  the  course 
taken  by  Dr.  Sternberg,  as  he  went  under  orders  from  the  President,  and,  as  an  officer, 
had  no  alternative  but  to  obey  orders. 

Anticipating  what  might  ensue  from  this  ill-timed  visit,  which  might  have  other- 
wise been  made  profitable  in  Mexico,  Dr.  Gaston  introduced  a resolution  at  the 
meeting  of  the  American  Medical  Association  in  Chicago,  recommending  that  two 


490 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


additional  members  of  the  medical  profession  should  be  added  to  the  Commission, 
whose  acquaintance  with  the  language  and  customs  of  the  population  in  the  respect- 
ive countries  should  fit  them  for  assisting  in  the  investigation  of  the  scientific  aspect 
of  the  matter  by  the  skillful  bacteriologist  properly  placed  on  duty  by  the  Government. 

Notwithstanding  that  a motion  to  lay  on  the  table  was  rejected  and  the  resolution 
was  passed  in  a full  session  of  the  Association,  there  was  presented  a motion  to  recon- 
sider the  vote,  and  this  also  was  voted  down  by  the  Association.  On  the  last  morn- 
ing of  the  meetings,  when  the  number  present  was  small,  a preamble  touching  the 
work  of  Dr.  Sternberg  was  accompanied  by  a resolution  rescinding  the  previous  action, 
and  though  this  was  claimed  by  Dr.  Gaston  to  be  out  of  order,  it  was  held  open  for 
consideration  by  the  President  of  the  Association.  A motion  to  consider  the  pre- 
amble and  resolution  separately  was  seconded,  but  was  precluded  by  a call  for  the 
previous  question,  which  was  sustained. 

Thus  the  resolutions  passed  at  a full  session  of  the  American  Medical  Association, 
over  a motion  to  lay  on  the  table  and  one  subsequently  to  reconsider,  were  rendered 
of  no  effect,  and  we  now  stand  where  the  officials  of  the  Government  of  the  United 
States  had  previously  placed  the  matter. 

In  the  memorial  which  had  been  provided  for,  the  names  of  Dr.  Guiteras, 
familiar  with  Mexico,  and  of  Dr.  H.  M.  Lane,  resident  for  a number  of  years  in 
Brazil,  were  proposed  as  proper  for  adding  to  the  Commission,  and  the  importance  of 
such  an  increase  of  the  persons  for  the  proper  execution  of  such  duties  as  devolve 
upon  this  Commission,  must  be  evident  to  all  who  have  taken  the  trouble  to  examine 
this  subject. 

Believing  that  the  sense  of  this  Section  should  be  expressed  without  bias  from 
local  or  personal  considerations,  the  following  preamble  and  resolutions  were  respect- 
fully submitted  and  unanimously  adopted  : — 

W hereas,  Inoculation  against  yellow  fever,  if  it  proves  upon  further  examina- 
tion to  be  successful,  is  calculated  to  confer  great  benefits  upon  the  human  race 
throughout  the  world  ; and 

Whereas,  The  facts  observed  by  Dr.  Domingos  Freire  afford  a reasonable  assur- 
ance of  protection  in  Rio  de  Janeiro  ; therefore 

Resolved , That  this  Section  recommends  thorough  investigation  of  inoculation 
against  yellow  fever,  and  that  adequate  appropriations  be  made  by  the  several  Gov- 
ernments represented  in  this  Congress  for  this  object ; 

Resolved , That  this  action  be  communicated  for  consideration  in  the  general  ses- 
sions of  the  Congress. 

The  resolutions  of  Dr.  Gaston  were  transmitted  to  Dr.  N.  S.  Davis,  President 
of  the  Ninth  International  Medical  Congress. 

As  a matter  of  historical  record,  Dr.  Jones  here  embodies  in  the  Transactions  of 
the  Fifteenth  Section  the  original  letters  of  Professor  Freire,  of  Brazil,  and  of  Pro- 
fessor Carmona,  of  Mexico. 

Rio  de  Janeiro,  8 Octobre,  1886. 

Cher  Confrere: — J’ai  l’honneur  de  rendre  rGponse  a votre  aimable  lettre  datGe  du  28  Aoflt. 
Je  vous  fGlicite  pour  la  position  que  vous  a cte  confiee  en  qualite  de  President  d'une  des  plus 
importantes  Sections  du  Congres  International  qui  se  reunira  a Washington.  Je  suis  sfir  que 
vous  saurez  accomplir  cotte  tacho  avec  tout  lo  profit  pour  la  scienco  ct  1’humanitG.  Lo  pro- 
gramme quo  vous  avez  bicn  voulu  me  remettre  comprend  des  sujets  du  plus  haut  intGret,  et  sans 
doute  quo  lcur  discussion  sera  des  plus  lumineuses. 

Quant  aux  questions  quo  vous  mo  faites,  je  vous  rfiponds  cointne  il  suit: — 

A la  premiere  que  jo  mo  regarde  tres  lieuroux  d’avoir  meritG  le  grand  honneur  d etre  choisi 
Vice-Prdsident  do  la  Section  dont  vous  etes  lo  digno  President,  et  jo  m’empresse  de  vous  envoyer 
mille  remerciemcnts  pour  ce  motif. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  491 


A la  deuxiemo  qu’il  me  sera  peut-etre  possible  d’aller  comme  delegue  du  Gouvernement  Bre- 
silien  ; et  pour  cela  je  tacherai  de  faire  les  demarches  n6cessaires. 

Quant  a la  troisieme  question,  je  reponds  6galement  affirmativement.  Je  ferai  un  rapport 
r6sum6  de  tous  les  points  eoncernant  la  fievre  jaune,  en  l’aceompagnant  de  tous  les  documents 
n6eessaires  pour  illustrer  non  seulement  la  partie  clinique  proprement  dite,  inais  encore  les  releves 
statistiques  reeueillis  jusqu’ici. 

Agr6ez,  mon  eher  illustre  confrere,  Texpression  sincere  de  mes  sentiments  les  plus  devoues. 

Domingos  Freire. 


N.  B.  Je  vous  remets  avee  cette  lettre  une  brochure  sous  lc  titre:  Notice  aur  la  Regeneration 
de  la  Virulence  dea  Cultures  Attenuees  du  Microbe  de  la  Fievre  Jaune,  que  j’ai  1’honneur  de  sou- 
mettre  a votre  consideration. 

Je  vous  remets  aussi  la  statistique  de  l’annee  1885. 


Dr.  Joseph  Jones. 


Mexico,  le  20  Octobre,  1886. 


Monsieur. — N’6tant  pas  a Mexico  a 1’epoque  de  l’arrivee  de  votre  lettre,  datee  le  28  Aofit  de 
la  Nouvelle-Orleans,  je  n’etais  pas  en  possibility  de  vous  repondre  immediatement. 

Aujourd’hui  je  le  fais  en  vous  disant: 

1°  Que  j’accepte  volontiers  l’offre  que  vous  me  faites  d’etre  nommS  un  des  Vice-Presidents 
de  la  quatorzieme  Section,  pour  representer  la  Republique  du  Mexique  dans  la  prochaine 
reunion  du  Congres  Medical  International. 

2°  Queje  serai  present  a Washington  le  5 Septembre,  1887,  pour  representer  la  meme  Re- 
publique, dans  la  quatorzieme  Section  du  Congres  Medical  International. 

3°  Que  je  ferai  un  ecrit  sur  mes  travaux  relatifs  a la  fievre  jaune  et  sur  les  resultats  des  ino- 
culations preventives  de  ce  terrible  fleau. 

Agreez  Mr.  le  Dr.  l’assurance  de  ma  consideration  aistinguee. 

Dr.  M.  Carmona  y Vall£. 


METROPOLITAN  DEFENSES  AGAINST  INFECTIOUS  DISEASES. 

DEFENSES  METROPOLITAINES  CONTRE  LES  MALADIES  CONTAGIEUSES. 

DIE  VERTHEIDIGUNGSMITTEL  DER  ENGLISCHEN  METROPOLE  GEGEN  INFECTIOSE 

KRANKIIEITEN. 

BY  EDWARD  SEATON,  M.D.,  F.R.C.P.,  ETC., 

London,  England. 

In  this  Section  of  Public  Hygiene  no  subject  can  be  more  important  than  that  of 
the  system  of  defenses  against  the  spread  of  infectious  fevers  in  great  cities;  for  with 
the  rapid  increase  in  the  facilities  of  travel,  every  community  is  more  or  less  dependent 
for  its  freedom  from  invasion  on  the  perfection  of  those  arrangements  in  the  towns  with 
which  it  is  in  frequent  communication.  A person  incubating  a disease  which  takes 
twelve  days  to  develop,  may,  during  that  period,  not  only  travel  from  London  to  dis- 
tant parts  of  the  continent  of  Europe,  hut  may  reach  America  before  the  disease  declares 
itself.  I need  not,  therefore,  excuse  myself  for  bringing  before  you  a brief  description 
of  the  system  of  defenses  against  infectious  diseases  in  our  English  metropolis,  or,  to 
speak  more  precisely,  that  part  of  our  system  which  comprises  the  isolation  and  treat- 
ment of  the  infectious  sick. 

In  discussing  this  subject,  it  is  always  well  to  have  in  mind  an  ideally  perfect  arrange- 
ment for  the  prevention  of  epidemics  by  quarantine  or  isolation  for  a large  town,  and 


492 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


I will,  therefore,  quote,  from  an  official  report  of  my  own,  a description  of  such  arrange- 
ments, which  are  ideal  in  the  sense  that  they  are  none  of  them  carried  out  in  entirety 
in  any  of  our  large  towns,  but  which  have  been  proved  to  be  practicable,  not  only  by 
tbe  experience  of  some  of  the  towns  in  England,  but  also,  I believe,  by  that  of  import- 
ant cities  on  this  great  continent  of  America. 

The  Corporation,  or  Town  Council,  delegates  its  principal  functions  as  sanitary 
authority  to  a “Health  Committee,”  which  has  charge  of  all  the  arrangements  for  pre- 
venting epidemics.  The  Medical  Officer  of  Health  is  tbe  responsible  adviser  of  this 
committee,  and  being  also  its  chief  executive  officer  in  work  which  is  distinctly  medi- 
cal, he  is  placed  in  a position  of  great  trust.  He  is  armed  with  sufficient  powers. 
All  householders  are  required,  under  penalty,  to  notify  to  him  the  existence  of  danger- 
ous, infectious  diseases,  to  wit,  cholera,  typhus  fever,  smallpox,  enteric  fever,  diph- 
theria and  scarlet  fever,  it  being  recognized  that  their  concealment  may  be  a risk  to  the 
whole  community.  The  medical  gentlemen  who  are  in  professional  attendance  on  such 
cases  are  required,  for  a fee,  to  furnish  certificates  of  the  nature  of  the  disease,  on  printed 
forms,  with  which  they  are  kept  supplied.  Information  from  these  sources  is  usually 
reliable  and  complete,  but  it  may  be  supplemented  by  that  which  comes  from  relieving 
officers,  school  board  inspectors,  clergy,  district  visitors  and  others.  From  wherever  it 
comes,  it  converges  in  one  centre — the  office  of  the  health  department.  This  office  is 
in  a convenient  situation,  and  open  to  the  public  at  all  hours.  It  is  under  the  control 
of  the  medical  officer,  who  visits  it  frequently,  and  when  absent  is  represented  by  the 
chief  inspector  or  clerk,  who  is  well  acquainted  with  his  movements.  From  the  office 
messages  may  be  sent  to  the  ambulance  stations  or  to  the  “ isolation  ” hospital.  Of  the 
“ epidemic  ” or  “ isolation  ” hospital  it  is  needless  to  say  more  than  that  its  situation 
is  sequestered,  away  from  the  vicinity  of  dwellings,  but  at  the  same  time  not  too  remote 
from  the  population  it  is  iutended  to  serve  ; its  appearance  is  attractive,  and  its  admin- 
istration free  from  all  taint  of  pauper  associations.  Here,  also,  as  at  the  office  of  the 
health  department,  everything  is  under  the  control  of  the  medical  officer,  who  is  respon- 
sible for  keeping  the  town  free  from  epidemic  disease.  It  is  understood  that  the  hospital 
exists  for  this  purpose.  It  must  be  ready  for  use  at  any  moment,  though  it  may  be 
empty  for  months  together.  The  expense  of  maintaining  it,  with  its  nursing  staff 
constantly  in  efficient  working  order,  is  considerable,  but  the  enlightened  rate-pavers 
regard  the  outlay  for  this  purpose  as  they  do  that  for  keeping  up  the  fire  brigade. 
Close  to  the  hospital  buildings  are  some  empty  but  furnished  houses,  into  which  persons 
who  have  been  exposed  to  the  infection  of  smallpox  or  typhus  fever  can  be  received  for 
that  period  (about  a fortnight)  in  which  the  disease  may  be  incubating,  or  in  course  of 
development,  during  which  it  is  desirable  they  should  be  under  medical  supervision. 
The  committee,  representing  a corporation  powerful  in  its  resources,  is  not  only  able  to 
enforce  the  seclusion  of  individuals  for  the  public  good,  but  is  also  ready  to  board  them, 
pay  their  wages,  and  even  to  afford  them  reasonable  compensation  for  any  loss  of  busi- 
ness they  may  sustain.  Furthermore,  the  arrangements  for  immediately  isolating  the 
sick,  and  watching  those  who  may  become  centres  of  infection,  are  supplemented  by 
ample  provision  for  disinfection  of  houses,  bedding,  clothing  and  furniture,  which  is 
scientifically  and  rigidly  applied.  To  this  it  may  be  added,  that  in  the  case  of  smallpox 
no  system  of  prevention  is  perfect  which  does  not  amply  provide  for  vaccination  or 
revaccination  at  the  infected  house  and  neighborhood.  In  England  the  arrangements 
are  under  the  control  of  the  poor  law  or  destitution  authority,  but  this  is  wisely  sup- 
plemented, in  some  towns,  by  the  health  authority,  which  provides  free  vaccination  to 
those  who  have  been  exposed,  or  are  likely  to  be  exposed,  to  infection,  and  this  is 
offered  to  them  at  their  homes. 

The  above  is  an  outline  of  the  general  conditions  for  dealing  successfully  with  infec- 
tious diseases,  to  be  fulfilled  in  the  case  of  a large  town.  The  larger  the  town  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


493 


greater  must  be  tlie  difficulty  of  fulfilling  such  conditions.  In  the  metropolis,  with  its 
vast  inhabited  area  and  its  huge  population,  the  difficulties  are  exceptional,  and  it  is 
no  wonder  that  it  is  only  by  slow  degrees  that  they  are  being  overcome. 

The  greatest  of  all  the  difficulties  arises  from  the  want  of  unity  and  uniformity  in 
London  municipal  government.  There  is  no  one  corporation,  town  council  or  board 
of  health  for  Loudon,  as  there  is  for  the  large  provincial  towns  in  England,  as  well  as 
for  Glasgow  and  Edinburgh.  There  is  a multiplicity  of  authorities  for  the  metropolis, 
but  no  one  authority  to  undertake  the  whole  work  of  preventing  the  spread  of  infec- 
tious diseases  within  the  metropolitan  area.  There  are  the  several  Boards  of  Guardians, 
forty  in  number;  there  are  the  vestries,  also  forty  in  number;  there  is  the  Metropolitan 
Asylums  Board,  and,  finally,  there  is  H.  M.  Local  Government — all  of  which  authorities, 
up  to  the  highest — the  Imperial  Department — have  a hand  in  the  work,  but  none  of 
which  are  saddled  with  the  whole  responsibility  of  dealing  with  epidemics.  The  neces- 
sity of  having  one  body  alone  to  undertake  this  work  is  coming  to  be  recognized  more 
and  more  by  those  who  take  a part  in  municipal  affairs,  and  by  degrees  the  Asylums 
Board,  as  it  is  called,  is  beginning  to  be  regarded  as  tbe  suitable  authority  for  the 
purpose. 

I will  not  enter  now  into  a discussion  of  the  circumstances  which  led  to  the  creation 
of  the  Board,  in  1867,  or  into  the  nature  of  the  functions  assigned  to  it,  or  the  character 
and  results  of  the  work  it  has  achieved  during  the  twenty  years  of  its  existence.  A 
most  interesting  report  of  the  Chairman  of  the  Board,  Sir  Edwin  Galsworthy,  published 
last  March,  which,  together  with  other  important  publications  of  the  Board,  have  been 
supplied  by  the  able  and  courteous  Clerk  of  the  Board,  Mr.  Jebb,  are  here  and  at  your 
service.  They  contain  full  information  on  those  points.  But  at  present  I will  only 
refer  to  them  as  indicating  the  difficulties  in  the  way  of  rendering  this  Board  more  effi- 
cient for  the  purposes  which  it  might  so  advantageously  fulfil.  Before  the  establish- 
ment of  the  Board,  in  1867,  London  was  dependent  for  its  infections  hospital  provisions 
upon  the  charities,  the  smallpox  hospital,  at  Highgate,  the  fever  hospital,  at  Islington, 
and  the  general  hospitals,  some  of  which  took  in  cases  of  infectious  diseases.  The 
various  Boards  of  Guardians  also  treated  cases  iu  imperfectly  isolated  wards  attached 
to  the  workhouses.  This  accommodation  was  very  insufficient,  and  in  the  case  of  the 
workhouses  the  aggregation  of  the  infectious  sick  in  proximity  to  the  paupers  consti- 
tuted a source  of  public  danger.  It  was,  no  doubt,  owing  to  the  difficulty  of  isolating 
infected  persons,  having  been  felt  mostly  in  the  case  of  paupers,  that  led  to  the  Asylums 
Board  being  established,  and  to  its  being  chiefly  constituted  of  representatives  of  the 
Board  of  Guardians.  This  was  most  unfortunate,  as,  by  its  constitution,  the  Board  has 
always  been  prevented  from  taking  a comprehensive  view  of  what  is  meant  by  the  preven- 
tion of  infectious  disease.  Its  name  indicates  this  fault.  It  is,  or  was,  intended  to  provide 
asylums,  or  places  of  refuge,  for  the  infectious  sick  and  for  imbecile  paupers.  The 
disadvantages  arising  from  the  origin  and  constitution  of  the  Board  are  twofold : In 
the  first  place,  its  policy  has  always  been  dictated  by  the  traditions  of  the  Poor  Law 
Board,  which  has  in  view  the  relief  of  destitution  at  the  least  possible  expense  to  the 
rate- payers;  whereas,  we  know,  from  the  teachings  of  sanitary  science,  that,  for  the  pre- 
vention of  epidemic  disease,  the  policy  of  a public  health  authority  must  be  guided  by 
very  different  principles.  In  the  second  place,  in  the  management  of  the  hospitals 
themselves  the  prevention  of  disease  is  entirely  subordinate  to  the  treatment  of  disease. 
One  example  of  this  fault  is  enough.  The  medical  treatment  of  persons  suffering  with 
smallpox  is  important,  yet  an  authority  which  was  guarding  the  public  health  would 
naturally  look  upon  its  prevention  as  still  more  important.  From  this  point  of  view, 
to  allow  unre vaccinated  nurses  to  attend  on  the  sick  would  be  more  unpardonable  than 
to  neglect  to  give  the  patient  such  medicines  or  wine  as  the  physician  deemed  necessary. 
Yet  it  had  to  be  admitted  in  Parliament,  three  years  ago,  that  unrevaccinated  nurses 


494 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


had  been  allowed  to  attend  upon  persons  suffering  from  smallpox.  Thirdly,  the  Board, 
being  saddled  with  the  responsibility  of  providing  for  the  imbecile  paupers  of  London, 
is  charged  with  the  supervision  of  a large  number  of  great  establishments,  and  is  unable 
to  concentrate  its  attention  on  the  prevention  of  epidemic  disease. 

Notwithstanding  the  defects  in  its  constitution,  the  Board  has  done  a great  deal 
toward  establishing  a good  system  of  defense  against  infectious  disease.  The  Local 
Government  Board  has  the  right  to  nominate  a third  of  the  members,  and  it  has  nomi- 
nated several  who  have  special  knowledge  or  experience  which  is  useful  to  the  Board. 
The  late  Chairman  of  the  Board,  Sir  Edmund  Currie,  showed  great  devotion  to  its 
interests,  and  brought  splendid  administrative  powers  to  its  service.  Under  the 
guidance  of  the  present  chairman,  Sir  Edmund  Galsworthy,  and  some  of  his  able  col- 
leagues, many  of  the  present  arrangements  have  been  perfected,  and  in  particular  the 
ambulance  arrangements  for  the  removal  of  patients  to  extra-mural  hospitals,  are  worthy 
of  attention.  As  it  will,  no  doubt,  be  interesting  to  the  Section,  I will  very  briefly 
describe  the  present  arrangement. 

The  hospital  provision  consists,  at  the  present  time,  of  five  intra-mural  and  three 
extra-mural  hospitals.  The  former  provide  for  as  many  as  1475  beds,  and  the  latter 
766.  So  that,  at  present,  the  total  accommodation  is  not  more  than  about  2000  beds 
for  a population  of  4,000,000.  The  five  intra-mural  hospitals  are  the  following: — 

1.  The  Eastern,  at  Homerton, 9 acres  of  land,  400  beds. 

2.  The  Northwestern,  at  Haverstock  Hill,  ....  11  “ 

3.  The  Western,  at  Fulham, 6 “ 

4.  The  Southwestern,  at  Stockwell, 8 “ 

5.  The  Southeastern,  at  Greenwich, 11  “ 


The  extra-mural  hospitals  are  the  following  : — 

The  hospital  ships  off  Dartford,  Kent;  350  beds,  for  smallpox. 

At  the  Gore  Farm,  near  Dartford,  are  a few  huts  ready  for  use. 

At  Winchmore  Hill  there  is  a convalescent  home  for  scarlet  fever,  with  room  for 
416  patients. 

All  cases  of  smallpox  are  now  removed  out  of  London  to  the  ships.  The  ambulance 
arrangements  are  excellent,  and  I can  testify,  from  personal  experience,  that  the  journey 
from  the  patient’s  home,  or  from  one  of  the  intra-mural  hospitals,  can  be  conducted 
without  any  detriment  to  the  patient.  There  is  j ust  a small  proportion  of  cases  which 
may  suffer  by  the  journey,  and  which  it  is,  indeed,  doubtful  whether  removal  from 
the  home  at  all  is  desirable.  I refer  to  cases  of  hemorrhagic  smallpox  and  women  in 
the  puerperal  state  affected  with  the  disease.  A committee  of  the  Board  is  at  present 
considering  the  question  of  the  best  means  of  dealing  with  such  cases.  The  recent 
observations  of  Dr.  Buchanan,  the  Medical  Officer  of  the  Government,  and  Mr.  Power, 
the  eminent  member  of  his  staff,  have  aroused  the  attention  of  all  observers  to  the  pos- 
sibility of  the-spread  of  smallpox  by  aerial  dissemination  of  the  particulate  matter  from 
hospitals.  The  committee  is  at  present  considering  the  feasibility  of  constructing  hos- 
pitals on  the  plan  recommended  by  Professor  Burdon-Sanderson,  for  consuming  all  their 
own  air,  and  any  observations  or  experience  which  can  be  furnished  by  the  members 
of  this  Congress  will  be  welcome. 


200  “ 
184  “ 
322  “ 
366  “ 


1472  “ 


DISCUSSION. 

Dr.  P.  H.  Bailiiache,  U.  S.  Marine  Hospital  Service,  referring  to  the  sugges- 
tion of  Professor  Sanderson,  as  quoted  by  Dr.  Seaton,  concerning  the  erection  of 
hospitals  constructed  to  consume  their  own  air,  stated  that  he  believed  that  such  a 
hospital  has  been  erected  in  Detroit,  Michigan. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  495 


OUTLINE  OF  INVESTIGATIONS  INTO  THE  NATURE,  CAUSES  AND 
PREVENTION  OF  ENDEMIC  AND  EPIDEMIC  DISEASES,  AND 
MORE  ESPECIALLY  MALARIAL  FEVER,  DURING  A PERIOD  OF 
THIRTY  YEARS,  WITH  A CLAIM  TO  PRIORITY  IN  THE  DETERMI- 
NATION OF  THE  CHEMICAL  AND  MICROSCOPICAL  CHARACTERS 
AND  CHANGES  OF  THE  BLOOD  IN  THE  VARIOUS  FORMS  OF 
MALARIAL  PAROXYSMAL  FEVER  AND  THE  APPLICATION  OF 
THE  RESULTS  OF  THESE  INVESTIGATIONS  TO  MEDICAL  DIAG- 
NOSIS AND  MEDICAL  JURISPRUDENCE. 


RESUME  D’INVESTIGATIONS  DANS  LA  NATURE,  LA  CAUSE  ET  LA  PREVEN- 
TION DES  MALADIES  ENDEMIQUES,  SURTOUT  DE  LA  FIEVRE  PALUDEENNE. 
EXPERIENCE  DE  TRENTE  ANS  ET  PRETENTION  A LA  PRIORITE  DANS  LA 
DEFINITION  DES  CARACTERES  CHIMIQUES  ET  MICROSCOPIQUES,  DES 
CHANGEMENTS  DU  SANG  DANS  LES  DIVERSES  FORMES  DE  LA  FIEVRE  PA- 
LUDEENNE AIGUE,  ET  L’APPLICATION  DES  RESULTATS  DE  CES  DECOU- 
VERTES  A LA  DIAGNOSTIQUE  ET  A LA  JURISPRUDENCE  MEDICALES. 


UMRISS  DER  WAHREND  DREISSIG  JAHRE  ANGESTELLTEN  UNTERSUCHUNGEN  UBER 
DAS  WESEN,  DIE  URSACHEN  UND  VERHUTUNG  ENDEMISCHER  UND  EPIDEMISCHER 
KRANKHEITEN,  INSBESONDERE  DES  MALARIAFIEBERS,  MIT  PRIORITATSANSPRUCH 
AUF  DIE  BESTIMMUNG  DER  CHEMISCHEN  UND  MICROSCOPISCHEN  EIGENSCHAFTEN 
UND  VERANDERUNGEN  DES  BLUTES  IN  DEN  VERSCHIEDENEN  ARTEN  DES  INTERM1T- 
TIRENDEN  MALARIAFIEBERS,  UND  DIE  ANWENDUNG  DER  ERGEBNISSE  DIESER 
UNTERSUCHUNGEN  AUF  DIE  DIAGNOSE  UND  GERICHTLICHE  MEDICIN. 


BY  JOSEPH  JONES,  A.M.,  M.D., 
Of  New  Orleans,  La. 


The  investigations  of  the  author  on  the  physical,  chemical,  microscopical  and  patho- 
logical changes  of  the  blood,  organs,  secretions  and  excretions  in  human  beings  suffer- 
ing with  the  various  forms  of  malarial  fever,  were  instituted  iu  the  Marine  Hospital 
and  Poor  House  of  Savannah,  Georgia,  in  the  year  1856,  and  were  vigorously  prosecuted 
during  three  years,  1856,  1857  and  1858. 

My  first  publications  were  made  in  the  Southern  Medical  and  Surgical  Journal , 
edited  hy  Dr.  Henry  F.  Campbell  and  Dr.  Robert  Campbell,  and  published  in  Augusta, 
Georgia.  In  an  article  published  in  May,  1858,*  after  presenting  the  history,  symptoms, 
chemical  analyses  and  pathological  anatomy  of  the  case  of  diabetes  mellitus,  and  of 
several  cases  of  malarial  fever,  the  following  conclusions  were  reached: — 

If  we  compare  the  blood  of  these  cases  with  that  of  health,  and  with  the  blood  of 
the  patient  suffering  with  diabetes  mellitus,  we  will  observe  the  following  points  of 
agreement  and  disagreement: — 

1.  The  colored  blood  corpuscles  are  diminished  greatly  and  rapidly  in  malarial 
fever.  This  destruction  of  the  colored  blood  corpuscles  is  far  more  rapid  in  malarial 
fever  than  in  diabetes  mellitus. 

2.  The  salts  of  the  colored  blood  corpuscles  are  diminished  to  a remarkable  extent 
in  malarial  fever,  while  they  are  normal  in  amount  in  the  blood  of  diabetes  mellitus. 

3.  The  blood  coagulates  slowly  and  the  clot  is  soft  in  malarial  fever,  while  the 
reverse  was  the  case  in  this  specimen  of  diabetic  blood. 


• ®'“Case  of  Diabetes  Mellitus,”  treated  by  Joseph  Jones,  A.sr.,  M.n.  Southern  Medical  and 
Surgical  Journal,  New  Series,  Vol.  xiv,  Augusta,  Georgia,  May,  1858,  No.  5,  pages  290-315. 


496 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


4.  The  fibrin  is  often  diminished  in  malarial  fever,  and  the  serum  presents  a golden 
color,  while  in  this  case  of  diabetes  mellitus  the  fibrin  was  slightly  increased  and  the 
color  of  the  serum  was  normal.  That  the  poison  of  malarial  fever  induces  profound 
changes  in  the  colored  blood  corpuscles,  and  other  constituents  of  the  blood,  I have 
demonstrated  by  the  following  facts: — 

(а)  The  urine  of  patients  suffering  with  malarial  fever  contains  an  increased  quan- 
tity of  iron.  The  increase  of  the  iron  in  the  urine  is  subsequent  to  the  destruction  of 
the  colored  corpuscles  in  the  blood. 

(б)  In  examinations  of  the  organs  after  death,  from  all  the  forms  of  malarial  fever — 
intermittent,  remittent  and  congestive — I have  observed  that  the  dark  blood  of  the 
spleen  and  liver  do  not  change  to  the  arterial  hue  when  exposed  to  the  action  of  the 
oxygen  of  the  atmosphere.  After  death  from  phthisis,  cirrhosis  of  the  liver,  organic 
disease  of  the  circulatory  apparatus  and  apoplexy  and  mechanical  injuries,  as  far  as  my 
observations  extend,  the  blood  of  the  spleen  and  liver  always  changes  to  the  arterial 
hue  when  exposed  to  the  action  of  the  oxygen  of  the  atmosphere. 

(e)  Animal  starch  accumulates  in  the  malarial  fever  liver,  while  grape  sugar,  as  far 
as  my  observations  extend,  is  absent.  I have  tested  the  livers  of  malarial  fever  for 
grape  sugar  and  starch.  An  abundance  of  starch*  was  obtained,  without  a trace  of 
grape  sugar.  The  li  vers  were  set  aside  and  examined  after  intervals  of  twelve  hours. 
The  last  examination  was  made  thirty-six  hours  after  the  first.  At  every  examination 
the  result  was  the  same,  an  abundance  of  animal  starch  and  no  grape  sugar.  These 
facts  are  important,  not  only  in  their  bearing  upon  malarial  fever,  but  also  in  their 
bearing  upon  diabetes  mellitus.  M.  Cl.  Bernard  f has  demonstrated  that  the  transfor- 
mation of  glycogenic  hepatic  matter  (animal  starch)  formed  by  the  liver  into  glucose  is 
the  result  of  the  action  of  a special  ferment,  which  is  formed  and  exists  in  the  blood, 
independent  of  the  liver.  From  the  facts  which  we  have  previously  stated,  it  is  evident 
that  in  malarial  fever  this  ferment  is  destroyed,  while  the  liver  still  possesses  the 
power  of  transforming  the  nitrogenized  and  non-nitrogenized  elements  into  animal 
starch.  We  have  now  facts  sufficient  to  draw  important  distinctions  between  malarial 
fever  and  diabetes  mellitus.  In  both  diseases  the  blood  corpuscles  may  be  greatly 
diminished.  In  both  diseases  the  nervous  and  muscular  forces  may  be  correspondingly 
diminished.  Here  the  analogy  ceases. 

The  destruction  of  the  colored  corpuscles  is  rapid  in  severe  types  of  malarial  fever, 
and  slow  in  all  forms  of  diabetes  mellitus.  The  salts  of  the  blood  corpuscles  are  normal, 
if  not  increased,  in  this  case  of  diabetes  mellitus,  while  they  are  greatly  diminished  in 
malarial  fever.  In  malarial  fever  the  blood  loses  its  power  of  changing  its  color  in  the 
spleen  and  liver.  In  malarial  fever  the  color  of  the  liver  and  the  bile  is  altered,  and 
the  spleen  is  enlarged,  softened  and  filled  with  a purplish-brown  mud.  In  diabetes 
mellitus  all  the  organs  are  normal  in  appearance.  In  malarial  fever  the  blood  has  lost 
its  power  of  converting  animal  starch  into  glucose.  In  diabetes  mellitus  this  power  is 
greatly  increased. 

The  following  table  affords  a comparison  of  normal,  diabetic  and  malarial  blood: — 


*So  abundant  is  this  animal  starch  in  the  malarial  fever  liver,  that  if  a small  particle  of  the 
substance  of  the  liver  be  mashed  upon  a glass  slide,  treated  with  a saturated  solution  of  iodine  in 
alcohol,  and  viewed  under  the  microscope,  nuinorous  beautiful  blue  masses  of  this  animal  starch 
colored  by  the  iodine  will  bo  seen.  If  the  fibrous  capsule  be  torn  off  from  tho  surface  of  the  liver, 
spread  upon  a glass  slide,  and  treated  with  tincture  of  iodine,  these  blue  masses  will  be  seen  scat- 
tered among  the  meshes  of  tho  fibrous  tissue.  With  reference  to  the  discovery  of  animal 
starch,  see  American  Journal  of  the  Medical  Sciencce,  Oct.  1S57,  page  203. 

f Moniteur  de  Hopitaux,  April  14th,  1857 ; also,  American  Journal  of  Medical  Sciences, 
July,  1857,  page  203. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  497 


Normal 

Blood. 

Normal 

Blood. 

1 

Diabetic 

Blood. 

Malarial 

Blood. 

Malarial 

Blood. 

Malarial 

Blood. 

200.000 

240.000 

161.490 

122.447 

159.489 

166.551 

“ “ “ “ ‘ “ “ Liquor  Sanguinis 

100.000 

120.000 

120.000 

150.000 

80.961 

92.702 

74  275 
51.987 

86.978 
79  437 

89.203 

85.968 

Moist  “ “ “ “ “ “ “ 

4S0.000 

GOO.  000 

370.808 

207.948 

317.748 

343.872 

400.000 

520.000 

629.192 

792.052 

682.252 

656.128 

2.000 

3.500 

2.806 

1.925 

0.877 

1.450 

Fixed  Saline  Constituents  in  1U00  parts  of  Moist 

8.120 

10.500 

11.981 

0.841 

10.728 

1.648 

Fixed  Saline  Constituents  in  1000  parts  of  Dried 

65.000 

70.000 

49.916 

3.240 

42.914 

6.595 

Fixed  Saline  ‘Constituents  in  1000  parts  of  Dried 

70.000 

80.000 

56.108 

27.083 

36.341 

37.909 

Fixed  Saline  Constituents  in  1000  parts  of  Solid 

88.053 

95.000 

68.488 

44.779 

30.205 

75.558 

Fixed  Saline  Constituents  in  1000  parts  of  Liquor 

8.550 

10.100 

5.320 

3.326 

2.647 

6.630 

We  have  now  all  the  necessary  facts  for  the  intelligent  treatment  of  this  case.  The 
indications  in  the  treatment  of  this  case  of  diabetes  mellitus  are: — 

1.  To  strengthen  digestion.  His  stomach  fails  to  digest  the  nitrogenized  elements, 
the  substances  which  he  needs  to  supply  the  rapid  waste  of  his  tissues. 

2.  To  afford  the  organic  and  inorganic,  materials  of  structure. 

3.  To  quiet  and  strengthen  the  nervous  system. 

4.  To  arrest  the  destruction  and  transformation  of  the  elements  of  the  blood,  tissues 
and  food  into  animal  starch  and  grape  sugar. 

The  article  on  diabetes  mellitus  was  followed  by  nine  articles  published  in  nine  con- 
secutive numbers  of  the  Southern  Medical  and  Surgical  Journal,  extending  from  June, 

1858,  to  February,  1859,  inclusive,  giving  53  cases  of  malarial  fever  in  detail,  illustrated 
by  the  details  of  16  autopsies,  66  analyses  of  the  urine,  and  nine  elaborate  analyses  of 
the  blood,  the  whole  constituting  a closely  printed  octavo  of  235  pages.* 

At  the  meeting  of  the  American  Medical  Association  in  Louisville,  Kentucky,  in 

1859,  the  author  presented  an  extended  memoir,  based  upon  his  physical,  chemical, 
microscopical  and  pathological  investigations  of  the  various  forms  of  malarial  fever, 
embraced  in  six  chapters,  and  covering,  in  a closely  printed  volume  of  419  pages,  the 
results  of  the  critical  study  of  several  hundred  cases  of  malarial  fever  (intermittent, 
remittent,  congestive  and  pernicious),  illustrated  by  elaborate  tables  of  the  changes  of 
the  temperature,  pulse  and  respiration,  and  of  the  blood,  urine  and  organs  in  the  various 
stages  of  the  disease. f In  this  work  the  author  endeavored  to  delineate  correctly  the 
natural  history,  chemistry  and  pathology  of  the  various  forms  of  malarial  fever,  and  to 
base  upon  these  results  a rational  and  scientific  method  of  treatment. 

Preceding  this  publication  medical  literature  possessed  only  a few  detached  obser- 
vations relating  to  intermittent  fever,  but  possessed  no  systematic  investigations  detail- 
ing the  changes  of  the  pulse,  respiration,  temperature,  blood,  urine  and  organs,  in  the 
various  forms  of  malarial  fever. 

With  reference  to  the  blood,  it  was  clearly  established  by  these  investigations,  which 
preceded  the  American  Civil  War — 

1.  That  the  malarial  poison  rapidly  destroys  the  colored  blood  corpuscles  in  all  the 
various  forms  of  intermittent,  remittent  and  congestive  fever. 

•“  Observations  on  Malarial  Fever,”  by  Joseph  Jones,  A.M.,  M.D.  Southern  Med.  and  Surg. 
Jour.,  J une,  J uly,  August,  September,  October,  November,  December,  1858;  January  and  February, 
1859;  New  Series,  Volumes  xiv  and  xv,  Augusta,  Georgia. 

f “ Observations  on  some  of  the  Physical,  Chemical,  Physiological  and  Pathological  Phenome- 
na of  Malarial  Fever,”  by  Joseph  Jones,  a.m.,  m.d.  The  Transactions  of  the  American  Medical 
Association,  Vol.  xir,  Philadelphia,  1859,  pages  209-627. 

Vol.  IV— 32 


498 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


2.  The  destruction  of  the  colored  blood  corpuscles  may  take  place  rapidly  during 
the  active  stages  of  the  disease  or  more  slowly  during  the  chronic  stages  of  the  disease. 

3.  The  destruction  of  the  colored  blood  corpuscles  was  demonstrated  both  by  chemi- 
cal and  microscopical  analyses,  and  the  peculiar  appearance  presented  by  the  pigments, 
granules  and  colorless  corpuscles  pointed  out. 

4.  The  fibrin  is  decreased  in  the  various  forms  of  malarial  fever,  and  the  changes  in 
the  physical  and  chemical  characters  of  this  element  were  applied  to  the  explanation  of 
certain  phenomena  witnessed  more  especially  in  the  hemorrhagic  fevers. 

5.  The  changes  in  the  color  of  the  liver  and  spleen  in  malarial  fever  are  shown  to 
be  characteristic  of  this  disease,  and  to  be  due  chiefly  to  the  action  of  its  poison  upon 
the  colored  blood  corpuscles. 

6.  The  microscopical  and  chemical  differences  between  the  changes  of  the  blood  and 
organs  in  malarial  and  yellow  fevers  were  carefully  defined. 

7.  Principles  of  treatment,  based  upon  the  results  of  chemical  and  microscopical 
analyses  and  investigations  with  the  thermometer,  and  upon  pathological  research. 

In  1859  and  1860,  the  author  undertook  an  extended  investigation  of  the  diseases  of 
the  various  geological  and  physical  divisions  of  the  Southern  (slave  States).  The  investi- 
gations of  the  soil,  waters  and  diseases  of  the  rice  plantations,  low  grounds  and  swamps 
of  Georgia  first  engaged  his  attention.  One  of  the  most  important  objects  of  this  inves- 
tigation was  the  determination,  by  chemical  analyses  and  microscopical  investigations, 
and  by  experiments  upon  living  animals,  of  the  natural  cause  of  the  various  forms  of 
malarial  fever. 

The  accomplishment  of  this  end  necessitated  extensive  travel  among  the  swamps 
and  rice  fields,  and  careful  chemical  and  microscopical  examination  of  the  waters,  and 
the  following  facts  were  determined,  which  have  a direct  bearing  upon  the  subject  now 
under  investigation: — 

1.  The  complex  chemical  nature  of  the  soil  and  waters,  and  especially  of  the  organic 
matters. 

2.  The  vast  variety  of  vegetable  and  animal  microorganisms  found  in  the  waters 
of  the  swamps,  rice  fields,  creeks,  marshes  and  rivers  of  the  malarial  regions  of  the 
Southern  States. 

3.  The  poisonous  nature  of  the  exhalations  from  the  stagnant  waters  of  swamps  and 
rice  fields  and  their  power  to  induce  dysentery  and  malarial  fever  in  human  beings. 

4.  The  poisonous  nature  of  the  waters  of  swamps  and  rice  fields  and  their  power  to 
induce  the  various  forms  of  malarial  fever  when  drunk  by  human  beings. 

5.  The  poisonous  nature  of  the  stagnant  waters  of  swamps  and  rice  fields  when 
injected  subcutaneously  into  living  animals. 

As  far  as  our  researches  extend  these  were  the  first  experiments  ever  devised  in  the 
history  of  medicine  for  the  direct  solution  of  the  problem  of  the  poisonous  properties 
of  the  stagnant  waters  of  swamps,  marshes  aud  rice  fields  by  introduction  into  the 
blood  of  animals. 

As  these  researches  contained  much  matter  of  value  to  the  agriculturist,  and  as 
they  contained  not  merely  numerous  analyses  of  the  soil,  minerals  aud  waters  of  Georgia 
and  South  Carolina,  and  the  results  of  an  extended  search  for  the  beds  of  phosphates 
which  have  in  late  years  proved  of  so  great  value  to  the  agriculturists  of  America  and 
Europe,  but  also  elaborate  hygienic  and  sanitary  rules  for  the  guidance  of  the  laborers 
in  the  rice,  sugar  and  cotton  plantations,  many  of  the  results  were  embodied  in  a 
paper  or  volume  of  319  pages  to  the  Cotton  Planters’  Couvention.* 

During  the  American  Civil  War,  1861-1865,  the  author  conducted  an  extended 
series  of  investigations  upon  the  diseases  of  the  troops  in  the  field  and  in  the  military 


*“  First  Reports  to  tho  Cotton  Planters'  Convention  of  Georgia  on  the  Agricultural  Resources 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  499 

hospitals  in  Virginia,  North  Carolina,  South  Carolina,  Georgia  and  Tennessee,  and 
among  the  Federal  prisoners  confined  in  Richmond,  Va.,  and  Andersonville  (Camp 
Sumter),  Georgia,  and  a large  number  of  the  cases  of  typhoid  and  malarial  fever 
f passed  under  his  observation  in  the  field  and  general  hospitals,  and  in  the  beleaguered 
towns  and  cities.  The  great  military  hospitals  of  the  Confederate  armies  located  in 
Gordonsville,  Charlottesville,  Virginia,  Charleston,  South  Carolina,  Savannah,  Augusta, 
Atlanta,  Marietta,  Macon,  Vineville  and  Andersonville,  Georgia,  afforded  the  grandest 
field  ever  offered  to  a Southern  physician  and  surgeon  for  the  investigation  of  the  various 
forms  of  endemic,  epidemic  and  contagious  fevers,  and  of  the  gunshot  wounds,  casual- 
ties and  diseases  incident  to  the  campaigns  and  battles  of  great  armies. 

A careful  consideration  of  the  causes  which  the  author  has  recorded  in  his  “ Medi- 
cal and  Surgical  Memoirs,”  Volume  II,  pp.  152-161,  with  reference  to  the  microorgan- 
isms of  the  intestinal  canal,  and  of  the  mesenteric  and  Peyer’s  glands  and  urine  in 
typhoid  fever,  and  the  comparison  of  these  with  the  subsequent  observations  of  Klebs 
and  others,  justify  the  claim  of  the  author  as  one  of  the  discoverers  of  the  microorgan- 
isms of  typhoid  fever. 

During  the  civil  war,  1861-1865,  he  had  no  means  of  presenting  his  labors  to  the 
scientific  world. 

These  investigations,  with  accurate  details  of  cases,  with  elaborate  drawings,  were 
continuously  forwarded  to  the  Surgeon-General’s  office  in  Richmond,  Virginia,  in  1862, 
1863  and  1864,  and  constituted  three  large  manuscript  volumes. 

These  labors  were  destroyed  by  fire  at  the  time  of  the  burning  of  the  Confederate 
capital. 

The  author  retained  the  first  and  original  draft  of  the  cases  and  drawings,  and  from 
them  he  has  reproduced  the  details  and  illustrations  recorded  in  the  second  volume  of 
his  “ Medical  and  Surgical  Memoirs.” 

We  will  content  ourselves  with  the  mere  record  in  a foot-note  of  some  of  the  publi- 
cations relating  to  malarial  fever  and  kindred  diseases.* 

After  a continuous  term  of  service  in  the  Charity  Hospital  of  New  Orleans,  from 
October,  1868,  to  April,  1870,  during  which  period  the  author  was  continuously  and 


of  Georgia,”  by  Joseph  Jones,  m.d.,  Augusta,  Georgia,  1880;  see  also  “Medical  and  Surgical 
Memoirs,”  containing  Observations  on  the  Geographical  Distribution,  Causes,  Nature,  Relations 
and  Treatment  of  Various  Diseases,  1855-1856,  by  Joseph  Jones,  m.d.,  Volume  ii,  New  Orleans, 
1887,  pp.  1111-1116. 

* “ Sulphate  of  quinine  administered  in  small  doses  during  health  is  the  best  means  of  prevent- 
ing chills  and  fever  and  bilious  fever  and  contagious  fever  in  those  exposed  to  the  unhealthy  climate 
of  the  rich  lowlands  and  swamps  of  the  Southern  Confederacy,"  by  Joseph  Jones,  m.d.  Southern 
Medical  and  Surgical  Journal,  Volume  xvn,  No.  8,  Augusta,  Georgia,  August,  1861,  p.  593-614. 
■“Indigenous  remedies  of  the  Southern  Confederacy  which  may  be  employed  in  the  treatment  of 
malarial  fever,”  by  Joseph  Jones,  m.d.  Number  1,  Southern  Medical  and  Surgical  Journal, V olume 
xvn;  Number  9,  Augusta,  Georgia,  1861,  pp.  673-718.  Number  2,  Southern  Medical  and  Sur- 
gical Journal,  Volume  xvn,  No.  10,  October,  1861,  Augusta  Georgia,  pages  754-787.  “Rela- 
tions of  Pneumonia  and  Malarial  Fever,  with  practical  observations  on  the  Antip'riodic  or  Abor- 
tive method  of  treating  pneumonia,”  by  Joseph  Jones,  M.D.  Southern  Medical  and  Surgical 
Journal,  September,  1866,  page  229.  “On  the  prevalence  of  pneumonia  and  of  typhoid  fever  in 
the  Confederate  army  during  the  war  of  1861-1865,”  by  Joseph  Jones,  m.d.  “Sanitary 
Memoirs  of  the  War  of  the  Rebellion,”  collected  and  published  by  the  United  State?  Sanitary 
Commission,  New  York,  1867,  pago  335.  “ Investigations  of  the  Diseases  of  the  Federal  prison- 

ers confined  in  Camp  Sumter,  Andersonville,  Georgia,”  by  Joseph  Jones,  m.d.  “Sanitary 
Memoirs  of  the  War  of  the  Rebellion,”  collected  by  the  United  States  Sanitary  Commission,  New 
York,  pages  467-655.  “Trial  of  Henry  Werz,”  2d  Session,  40th  Congress,  1867-1868.  Execu- 
tive Document,  No.  23,  Medical  Testimony,  Dr.  Joseph  Jones.  “ Reports  embracing  description 


500 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


exclusively  engaged  in  clinical  studies  in  the  wards,  in  chemical  and  microscopical 
analyses  in  the  laboratory,  and  in  post-mortem  examinations  and  pathological  researches 
iu  the  dead-house,  the  cases  treated,  with  all  the  chemical,  microscopical,  pathological 
and  therapeutical  data,  and  anatomical  and  microscopical  specimens,  were  classified 
and  published,  for  the  use  of  the  medical  profession  and  the  students  of  the  medical 
departments  of  the  University  of  Louisiana,  in  two  groups. 

The  first  group  related  chiefly  to  diseases  of  the  nervous  system.* * 

The  second  group  embraced  the  microscopical  and  chemical  changes  of  the  blood  in 
malarial  fever,  diseases  of  the  circulatory  and  respiratory  system,  and  of  the  spleen, 
kidneys  and  liver. 

A large  portion  of  the  second  division  was  devoted  to  the  consideration  of  dropsy  as 
a symptom  of  various  diseases,  and  this  most  important  subject  was  discussed  under 
the  following  heads: — 

1.  Dropsy  arising  from  derangement  in  the  nutrition  of  the  tissues,  leading  either  to  an 
increase  of  secretion  or  a diminution  of  absorption. 

2.  Dropsy  arising  from  derangements  of  the  blood,  leading  to  derangements  of  the  nutri- 
tion of  the  tissues,  with  an  increase  of  secretion  or  a diminution  of  absorption. 

3.  Dropsy  arising  from  derangements  of  the  circulatory  apparatus,  attended  with  venous 
obstruction  and  congestion,  increased  serous  effusion  from  the  distended  blood  vessels  and 
diminished  absorption , cardiac  dropsy,  hepatic  dropsy. 

4.  Dropsy  arising  from  derangements  or  lesions  of  the  organs  which  regulate  the  amount 
of  the  blood,  as  well  as  its  constitution,  by  regulating  the  amounts  of  the  watery  elements , and 
by  the  elimination  of  excrementitious  materials.  Renal  dropsy. 

Each  division  was  illustrated  by  cases,  post-mortem  examinations  and  microscopical 
and  chemical  investigations,  and  the  changes  induced  by  the  action  were  noted  through- 
out the  entire  investigation;  but  it  was  chiefly  uuder  the  second  division  of  dropsy  that 
the  malarial  poison  was  recognized  as  a principal  factor,  in  the  profound  changes  it  pro- 
duced in  the  composition  of  the  blood. 

Thus  we  held  that  the  prolonged  action  of  the  malarial  poison  not  infrequently 
induces  such  changes  in  the  composition  of  the  blood,  and  such  derangements  in  the 
liver  and  spleen,  as  to  lead  to  the  effusion  of  serous  fluid  into  the  areolar  tissue  and 
peritoneum-abdominal  cavity.  The  changes  of  the  blood  induced  by  malarial  fever 
appear  to  be  the  chief  cause  of  the  dropsical  effusions,  although  in  some  cases  this  symp- 
tom may  be  attributed  to  the  mechanical  obstacle  afforded  by  the  enlarged  spleen  and 
liver. 


of  the  Stockade,  and  condition  of  the  prisoners  therein  confined,  and  condition  of  the  hospitals, 
etc,”  page  618,  page  641,  manuscript,  pages  1721  and  1766.  “Investigations  upon  the  nature, 
causes  and  treatment  of  Hospital  Gangrene  as  it  prevailed  in  the  Confederate  armies,  1861-1S65,” 
by  Joseph  Jones,  m.d.  “Surgical  Memoirs  of  the  War  of  the  Rebellion,” collected  and  published 
by  the  United  States  Commission,  New  York,  1867,  pages  142-5S0.  The  Charity  Hospital  of 
New  Orleans  has,  from  the  removal  to  this  city,  in  the  winter  of  1868,  up  to  the  present  moment,' 
furnished  an  extensive  field  for  investigation  in  therapeutics  and  pathology  upon  all  subjects 
relating  to  the  etiology,  pathology  and  treatment  of  fevers.  During  a period  extending  from 
1869-1886  inclusive,  the  cases  of  various  diseases  treated  by  the  author  in  the  wards  of  the 
Charity  Hospital  numbered  6311,  with  668  deaths  ; the  various  forms  of  malarial  fever  num- 
bered 2885  cases,  with  88  deaths.  During  this  period  a large  number  of  cases  of  malarial  fever 
were  also  treated  in  private  practice. 

* Memoranda  of  Medical  Clinic  at  Charity  Hospital,  New  Orleans,  Louisiana,  1869-1S70. 
By  Joseph  Jones,  M.  d.  Section  I.  Diseases  of  the  Nervous  System.  The  Neio  Orleans  Journal 
of  Medicine,  April,  1870,  pages  233-273.  Section  II.  Dropsy  Considered  as  a Symptom.  ATetc 
Orleans  Journal  of  Medicine,  July,  1870,  pages  484-563.  “ Medical  and  Surgical  Memoirs,”  by 
Joseph  Jones,  m.  d.,  New  Orleans,  Louisiana,  1876. 


ACADEMY 

OF 

medicine. 

SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  501 

After  the  illustration  of  the  effects  of  the  malarial  poison  in  altering  the  physical 
and  chemical  constitution  of  the  blood  and  in  inducing  dropsy,  by  elaborate  chemical 
analyses  and  by  the  detailed  reports  of  cases,  we  thus  formulated  the  general  results. 

1.  In  malarial  fever  Ike  specific  gravity  of  the  blood  and  serum  is  diminished.  The 
specific  gravity  of  the  blood  in  this  disease  ranges  from  1030.5  to  1042.4,  and  the  specific 
gravity  of  the  serum  from  1018.0  to  1023.6.  In  health,  on  the  other  hand,  the  specific 
gravity  of  the  blood  ranges  from  1055  to  1063,  and  the  specific  gravity  ot  the  serum 
from  1027  to  1032. 

2.  In  malarial  fever  the  colored  blood  corpuscles  are  greatly  diminished.  In  health  the 
dried  blood  corpuscles  may  vary  from  120  to  150  parts  in  the  1000  of  blood,  and  the 
moist  blood  corpuscles  from  480  to  600.  In  malarial  fever,  on  the  other  hand,  the  dried 
blood  corpuscles  range  from  51.98  to  107.81,  and  the  moist  blood  corpuscles  from  207 
to  323.63. 

The  careful  comparison  of  these  analyses  of  malarial  blood  with  each  other  reveals 
the  fact  that  the  extent  and  rapidity  of  the  diminution  of  the  colored  corpuscles  cor- 
responds to  the  severity  and  duration  of  the  disease. 

A short  hut  violent  attack  of  congestive  or  remittent  fever  in  its  severest  forms  will 
accomplish  as  great  a diminution  of  the  colored  blood  corpuscles  as  a long  attack  of 
intermittent  fever  or  the  prolonged  action  of  the  malarial  poison. 

3.  In  malarial  fever  the  relation  between  the  colored  corpuscles  and  liquor  sanguinis  is 
deranged.  Thus,  in  healthy  blood  the  relative  proportion  of  moist  blood  corpuscles  in 
the  1000  parts,  and  of  liquor  sanguinis,  may  vary  from  480.00  to  600.00  of  the  former, 
and  from  520.00  to  400.00  of  the  latter;  while  in  malarial  fever  the  globules  vary  from 
207.92  to  323.63,  and  the  liquor  sanguinis  from  792.08  to  676.37. 

4.  The  fibrin  of  the  blood  is  diminished  to  a marked  extent  in  most  cases  of  malarial  fever, 
and  is  altered  in  its  properties  and  in  its  relations  to  the  other  elements  of  the  blood,  and  to 
the  blood  vessels. 

5.  The  organic  matter  of  the  liquor  sanguinis,  and  especially  the  albumen,  is  diminished 
in  malarial  fever.  Thus  the  solid  matters  of  the  serum  may  vary  in  health  from  90.00 
to  105.00;  while  in  malarial  fever  they  vary  from  62.78  to  80.22  parts  in  the  1000  parts 
of  blood. 

It  is  chiefly  to  this  latter  change,  namely,  the  diminution  of  the  blood  in  malarial 
fever,  that  dropsical  effusions  are  to  be  traced. 

The  other  changes  of  the  blood  without  doubt  lead  to  congestions  of  the  liver  and 
spleen  and  to  derangements  of  the  capillary  circulation  and  nutrition  of  the  organs  and 
tissues  ; but  a careful  examination  of  three  diseases,  as  anaemia,  chorea  and  pyaemia, 
in  which  the  colored  blood  corpuscles  are  greatly  diminished,  will  show  that  this  cause 
alone  will  not  induce  dropsy. 

In  the  watery  state  of  the  blood  induced  by  the  action  of  the  paludal  poison,  com- 
paratively slight  obstructions  of  the  circulation  in  the  spleen  and  liver  might  lead  to 
dropsical  effusions.  It  would  appear  also  that  from  the  derangement  of  the  circulation 
caused  by  the  retention  of  the  malarial  poison  in  the  blood  and  nervous  system,  certain 
effete  products  are  not  sufficiently  and  properly  eliminated  from  them,  as,  for  instance, 
urea,  and  may  be  active  in  the  production  of  dropsy.  New  Orleans  Journal  of  Medicine, 
July,  1870,  pp.  498-500. 

During  the  past  18  years,  1879-1887,  I have  repeatedly  demonstrated  to  the  medical 
students  of  the  University  of  Louisiana,  in  the  wards,  amphitheatre  and  dead-house, 
the  diagnostic  characters  which  distinguish  the  blood  of  malarial  fever  from  that  of 
yellow  fever  and  other  diseases,  and  have  from  time  to  time  made  permanent  record 
of  various  portions  of  our  labors  in  the  medical  press.  * 


* See  Memoirs:  “Outline  on  Hospital  Gangrene,”  etc.  New  Orleans  Journal  of  Medicine, 


502 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  service  as  President  of  the  Board  of  Health  of  the  State  of  Louisiana,  1880-’  S4r 
necessitated  the  careful  and  scientific  examination  of  subjects  relating  to  the  nature, 
causationand  control  of  yellow  and  malarial  fevers;  and  certain  questions  arising  during 
the  progress  of  medico-legal  investigations  also  required  the  thorough  and  continuous  use 
of  the  microscope  in  the  determination  of  the  physical  and  minute  characters  of  human 
blood  in  health  and  disease. 

During  his  service  as  President  of  the  Board  of  Health  of  the  State  of  Louisiana 
during  these  four  years,  extending  from  April,  1880,  to  March,  1884,  the  author  was 
enabled  to  put  to  the  crucial  test  the  actual  application  of  every  principle  relative  to  the 
nature  and  exclusion  of  foreign  pestilence. 

During  the  period  specified  the  means  instituted  were  effective  in  excluding  yellow 
fever  from  the  Mississippi  Valley;  and  the  principle  of  diagnosis  based  upon  his 
clinical  and  pathological  researches  gave  precision  and  confidence  to  the  official 
decisions  of  the  Board  of  Health,  and  prevented  panic,  alarm  and  useless  quarantine.* 


January,  1869,  Vol.  xxii,  pp.  22-49  ; April,  1869,  pp.  201-234.  “ Leucocythaemia  or  Leukaemia" 

(white  cell  blood  or  white  blood).  Outline  of  clinical  lecture  delivered  in  the  Charity  Hospital 
by  Joseph  Jones,  m.  d.  New  Orleans  Journal  of  Medicine,  July,  1869,  pp.  425-438.  “Heart- 
clot.”  Outline  of  clinical  lecture  delivered  at  the  Charity  Hospital,  New  Orleans,  La.,  by  Joseph 
Jones,  M.D.,  New  Orleans  Journal  of  Medicine,  July,  1869,  pp.  469-487.  “Memoranda  of  Med- 
cal  Clinic,  at  Charity  Hospital,  New  Orleans,  1869  and  1870,”  by  Joseph  Jones,  m.d.  Sect.  1st: 
“Diseases  of  the  Nervous  System.”  New  Orleans  Journal  of  Medicine,  April,  1S70,  pp.  233-274. 
Sect.  2d  : “ Dropsy  considered  as  a symptom  of  various  diseases.”  New  Orleans  Journal  of  Med- 
icine, July,  1870,  pp.  484-563.  “Contributions  to  the  Natural  History  of  Yellow  Fever,”  by 
Joseph  Jones,  m.d.  New  Orleans  Medical  and  Surgical  Journal,  January,  1874,  Vol.  I,  New 
Series,  pp.  466-516.  “Contribution  on  Changes  of  the  Blood  in  Yellow  Fever,”  by  Jos.  Jones, 
M.  D.  %New  Orleans  Medical  and  Surgical  Journal,  September,  1874,  pp.  177-266.  “ Black  Vomit 

of  Yellow  Fever,”  by  Joseph  Jones,  m.d.  New  Orleans  Medical  and  Surgical  Journal,  Septem- 
ber, 1876,  pp.  159-165.  “ Malarial  Haematuria;  Nature,  History  and  Treatment ; illustrated  by 

cases,”  by  Joseph  Jones,  M.  d.  New  Orleans  Medical  and  Surgical  Journal,  February,  1S78, 
pp.  573-591.  “Medico-legal  evidence  relating  to  the  detection  of  human  blood,  presenting  the 
alterations  characteristic  of  malarial  fever  on  the  clothing  of  a man  accused  of  the  murder  of 
Narcisse  Arrieux,  December  26th,  1876,  near  Donaldsonville,  La.,”  by  Joseph  Jones,  m.d.  New 
Orleans  Medical  and  Surgical  Journal,  August,  1878,  pp.  101-123.  “Yellow  Fever  Epidemic 
of  1878  in  New  Orleans,  La.,”  by  Joseph  Jones,  m.  d.  New  Orleans  Medical  and  Surgical  Jour- 
nal, March,  1879,  pp.  683-715;  April,  1S79,  pp.  703-780;  May,  1879,  pp.  S50-872 ; June,  1879, 
pp.  942-971.  “ Comparative  Pathology  of  Malarial  and  Yellow  Fevers,”  by  Joseph  Jones,  m.d. 

Transactions  of  the  Louisiana  State  Medical  Society,  Annual  Session  of  1879,  New  Orleans  Med- 
ical and  Surgical  Journal,  Vol.  vri,  New  Series,  July,  1879,  pp.  106-217,  p.  297.  “ Treatment 

of  Yellow  Fever,”  by  Joseph  Jones,  m.d.  New  Orleans  Medical  and  Surgical  Journal,  Septem- 
ber, 1879,  pp.  344-365.  “Medical  and  Surgical  Memoirs,”  by  Joseph  Jones,  m.d.,  New  Orleans, 
La.,  1876,  p.  826;  Vol.  ii,  1887,  p.  1348. 

* “ Annual  Reports  of  the  Board  of  Health  of  the  State  of  Louisiana  to  the  General  Assem- 
bly, 1880-’83,”  Joseph  Jones,  m.d.,  President.  “ Quarantine  and  sanitary  operations  of  the  Board 
of  Health  of  the  State  of  Louisiana  during  the  years  1880-’83,”  by  Joseph  Jones,  m.d.,  p.  377, 
New  Orleans,  1884.  “ Measures  for  the  prevent  ion  an  1 arrest  of  contagious  and  infectious  diseases, 
including  smallpox  and  yellow  fever,”  by  Joseph  Jones,  m.d.,  New  Orleans,  Louisiana,  1884. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  503 


APPLICATION  OF  THE  RESULTS  OF  HIS  CHEMICAL,  MICROSCOPICAL  AND  PATHO- 
LOGICAL INVESTIGATIONS  AS  TO  THE  CHANGES  OF  THE  BLOOD  AND  ORGANS  IN 

THE  VARIOUS  FORMS  OF  MALARIAL  PAROXYSMAL  FEVER,  TO  MEDICAL  DIAG- 
NOSIS AND  MEDICAL  JURISPRUDENCE. 

If  it  be  true  that  the  malarial  poison  produces  distinct  and  specific  microscopical 
changes  in  the  blood  of  human  beings,  it  is  evident  that  we  have  in  such  changes 
valuable  data  for  diagnosis. 

It  will  be  admitted,  by  experienced  and  competent  observers,  that  medico-legal 
investigations  furnish  the  most  difficult  and  important  opportunities  for  the  crucial 
test  of  the  nature  and  value  of  changes  of  the  human  blood  under  the  action  of 
certain  poisons,  and  in  certain  casualties,  as  revealed  by  chemical  and  microscopical 
analysis. 

The  author,  in  the  discharge  of  certain  responsible  duties  imposed  upon  him  by  the 
legal  authorities  of  Louisiana,  was  compelled  to  record  his  observations  upon  the 
changes  of  the  blood  in  malarial  fever. 

As  far  as  our  information  extends,  this  is  the  only  case  in  which  the  pathological 
changes  of  the  blood  found  upon  the  garments  of  a man  charged  with  the  crime  of 
murder  was  determined  and  announced  officially,  in  advance  of  any  knowledge  of  the 
history  and  condition  of  the  murdered  man. 

Regarding  this  subject  as  of  importance  to  medical  as  well  as  to  legal  science,  we 
reproduce  it. 

MEDICO-LEGAL  EVIDENCE  RELATING  TO  THE  DETECTION  OF  HUMAN  BLOOD,  PRESENTING  THE 

ALTERATIONS  CHARACTERISTIC  OF  MALARIAL  FEVER,  ON  THE  CLOTHING  OF  A MAN  ACCUSED 

OF  MURDER.® 

The  value  of  life  and  property  in  every  country  depends  not  merely  upon  the  num- 
ber and  character  of  its  laws,  but  chiefly  upon  a learned  and  incorruptible  judiciary, 
supported  by  an  intelligent,  law-abiding  and  virtuous  people.  The  great  ends  of  good 
government,  the  security  of  life,  liberty,  property,  and  the  pursuit  of  happiness  to  all 
alike,  irrespective  of  birth,  condition  or  occupation,  can  be  secured  solely  by  the 
impartial  administration  of  just  laws  and  the  certain  and  prompt  punishment  of  their 
infraction. 

Holding  these  views,  the  writer  has  upon  various  occasions,  in  several  Southern 
States,  responded  to  the  calls  of  outraged  humanity  and  offended  justice,  and  assumed 
the  painful  and  responsible  task  of  instituting  those  post-mortem  examinations  and 
chemical  and  microscopical  processes  which  could  best  detect  and  reveal  the  modes  and 
causes  of  death,  and  thus  aid  justice  by  furnishing  an  important  link  of  evidence. 
Although,  during  the  past  twenty  years  I have  been  engaged  in  the  investigation  of 
over  fifty  cases  of  poisoning  by  various  agents,  as  arsenious  acid  (arsenic),  strychnia, 
morphia,  opium  and  its  preparations,  lead  and  its  salts,  sulphate  of  iron,  cyanide  of 
potassium,  the  seeds  of  the  Jamestown  weed  and  other  poisons,  and  although  these 
medico  legal  investigations  have  resulted  in  the  conviction  of  a number  of  criminals  ; 
as  the  processes  employed  were  similar  to  those  practiced  by  experienced  toxicologists, 
and  as  the  facts,  as  a general  rule,  are  well  known  and  carefully  recorded,  I have 
refrained  from  burdening  the  current  medical  literature  with  the  details.  I am 
induced,  however,  to  publish  the  following  details,  under  the  belief  that  they  will 
prove  of  interest  to  those  who  may  conduct  similar  examinations,  and  also  in  two  par- 
ticulars to  the  medical  profession  generally. 

The  phenomena  manifested  by  the  deceased  after  the  reception  of  the  blows  upon 
the  head,  as  well  as  the  detection  of  the  peculiar  effects  of  malarial  fever  upon  the 
blood  spattered  on  the  clothing  of  the  accused,  and  also  upon  the  floor,  walls  and  fur- 


* The  New  Orleans  Medical  and  Surgical  Journal,  August,  1878,  pp.  139-156. 


504 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


niture  of  the  room  in  which  the  murder  was  committed,  appear  to  be  worthy  of  record 
and  consideration. 

Circumstances  of  the  Murder. — Narcisse  Arrieux  was  found,  on  the  morning  of  Decem- 
ber 28th,  1876,  dead  in  his  store,  situated  on  the  banks  of  the  Mississippi,  near  the 
southwestern  border  of  the  town  of  Donaldsonville,  Louisiana.  The  head,  face,  beard 
and  clothing  of  the  old  man,  Narcisse  Arrieux,  were  covered  with  clotted  blood.  It 
was  evident,  from  an  extensive  compound  comminuted  fracture  of  the  cranium,  extend- 
ing on  the  right  side  from  the  occiput  across  the  right  parietal  bone  and  frontal  bone  to 
the  internal  canthus  of  the  left  eye,  and  from  several  other  contused  wounds  on  the 
head,  that  death  had  been  caused  by  blows  inflicted  by  heavy  blunt  instruments. 

The  small  house  occupied  by  Narcisse  Arrieux  as  a store  and  dwelling  contained 
three  apartments.  The  largest  apartment,  which  faced  the  Mississippi  river  and  opened 
by  a door  upon  the  common  road  or  highway  leading  up  and  down  the  road  behind 
the  broad  levee  which  protects  this  region  from  overflow,  was  used  as  a store  for  the 
sale  and  barter  of  various  kinds  of  merchandise,  food  and  spirits.  This  store  was 
divided  into  two  unequal  portions  by  a counter  running  directly  across  in  front  of  the 
door  ; the  space  behind  the  counter  was  much  less  in  area  than  that  in  front. 

Back  of  the  counter  and  communicating  with  the  main  room  or  store  were  two 
smaller  rooms,  one  of  which  was  used  as  a sleeping  apartment  and  the  other  as  an 
office  and  sitting  room.  According  to  the  testimony  of  the  coroner  and  other  witnesses, 
the  dead  body  of  Narcisse  Arrieux  was  found,  on  the  morning  of  the  28th  of  December, 
1876,  lying  near  the  stove,  on  an  overturned  chair  in  the  small  office.  The  doors  com- 
municating between  the  store  and  the  sleeping  room  and  office,  and  between  this  office 
and  the  sleeping  room,  were  open.  The  door  opening  from  the  street  into  the  public 
road  was  shut  and  locked.  A pool  of  blood  lay  on  the  floor  behind  the  counter,  near 
a barrel  of  alcoholic  spirits.  Traces  of  blood  were  also  found  upon  the  floor  of  the 
store,  and  marks  of  bloody  hands  were  also  upon  the  walls  and  upon  the  front  door, 
and  upon  the  floor  of  the  office  and  sleeping  room.  Marks  of  bloody  hands  were  found 
upon  the  walls  and  door  posts  and  upon  the  bed. 

Blood  was  also  found  upon  two  desks  and  in  the  drawers,  in  which  the  deceased  kept 
his  money  and  books.  Several  four-pound  iron  weights  containing  blood  and  the  gray 
hairs  of  the  deceased  were  found  behind  the  counter,  in  the  office  and  sleeping  apart- 
ment. One  of  these  heavy  iron  weights,  thrown  at  the  head  of  the  deceased,  had 
crashed  through  a window  in  the  back  part  of  the  sleeping  room,  and  was  picked  up  in 
the  yard.  According  to  the  statement  of  Dr.  John  E.  Duffel,  an  intelligent  and  accom- 
plished physician  of  Donaldsonville,  who  held  the  post-mortem  at  the  Coroner’s  inquest, 
the  wounds  observed  upon  the  head  of  Narcisse  Arrieux  were  as  follows  : — 

Left  Side. — Contused  wound  about  one-half  inch  in  length,  near  inner  canthus  of  left 
eye.  Contused  wound  one-half  inch  in  length,  at  root  of  nose  on  the  left  side,  pene- 
trating and  fracturing  the  frontal  bone.  Great  ecchymosis  of  both  eyes.  Contused 
wound  over  left  eye,  but  extending  diagonally  toward  the  left  temple,  penetrating  to 
the  bone  ; contused  wound  in  left  temple,  in  line  with  margin  of  left  eye.  Contused 
wound  on  posterior  part  of  the  head,  penetrating  to  the  bone.  Contused  wound  four 
inches  from  left  ear,  extending  backward  toward  occiput,  two  inches,  fracturing  and 
depressing  the  occipital  bone. 

Right  Side. — Contused  wound  on  forehead,  penetrating  to  the  bone,  about  three 
inches  across  the  root  of  the  nose.  Contused  wouud  about  one  inch  to  the  left  of  the 
ear  penetrating  to  the  bone.  Contused  wouud  starting  from  the  outer  margin  of  the 
eyebrows,  ranging  downward  toward  the  temporal  bone,  about  three  inches  in  length, 
ending  in  a line  with  the  top  of  the  right  ear,  penetrating,  fracturing  and  depressing 
the  right  temporal  bone. 

Scalp  Removed. — Extensive  fracture,  extending  from  the  iuuer  canthus  of  left  eye, 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


505 


upward,  in  a curve,  and  ranging  across  the  right  side  of  the  frontal  hone,  and  around, 
across  the  temporal  and  parietal  hones  to  the  occiput.  It  appears,  from  the  condi- 
tion of  the  premises  at  the  time  of  the  inquest,  that,  notwithstanding  the  extensive 
wounds  and  fractures  of  the  cranium,  the  deceased,  after  the  infliction  of  the  injuries 
and  after  the  flight  of  the  assassins  and  robbers,  had  partially  regained  his  senses  and 
the  use  of  his  limbs;  had  closed  his  door,  examined  his  money  drawers,  had  attempted 
to  light  a Are  in  his  stove,  had  placed  a newspaper  on  the  floor,  unbuttoned  and  pulled 
down  his  pantaloons  and  evacuated  his  bowels,  had  staggered  around  the  walls,  steady- 
ing himself  with  his  bloody  hands,  and  after  seating  himself  on  a chair  had  died  and 
fallen  upon  the  floor,  overturning  the  chair  and  lying  upon  the  floor  with  his  legs  bent. 
He  appeal's  to  have  died  in  the  sitting  posture,  and  after  death,  and  even  after  the 
establishment  of  the  rigor  mortis,  the  body  had  fallen  upon  the  floor.  It  appears,  from 
the  testimony,  that  between  the  hours  of  9 and  11  o’clock  P.M.,  on  the  night  of  the 
27th  (a  dark  and  stormy  night),  four  powerful,  stalwart  negro  men  entered  the  store  of 
Narcisse  Arrieux  and  called  for  ardent  spirits.  As  the  old  man  turned  his  back  to 
draw  the  liquor  from  the  barrel,  he  was  struck  by  one  or  more  of  the  robbers,  with  a 
four-pound  iron  weight,  on  the  back  of  the  head.  This  blow  not  having  the  effect 
desired  by  the  assassins,  the  weights  upon  the  counter  were  hurled  in  rapid  succession 
against  his  head.  The  powerful  leader  of  the  robbers  sprang  over  the  counter  and 
inflicted  repeated  blows  upon  his  head  with  a short  hickory  stick  armed  with  a leaden 
head,  which  had  been  carried  concealed  in  the  sleeve  of  his  coat.  It  is  probable  that 
the  victim  lay  unconscious  during  the  robbery  of  the  store,  and  after  the  assassins 
had  withdrawn,  the  profuse  hemorrhage  (as  shown  by  the  large  pool  of  blood  behind 
the  counter  where  he  fell)  relieved  the  congestion  of  the  brain  temporarily,  and  upon 
the  return  of  consciousness  he  was  able  to  stagger  to  the  door  and  close  it,  and  to  visit 
his  office  and  sleeping  room,  and  even  to  examine  the  desks  in  which  he  kept  his  money 
and  books. 

Prosecution  of  the  Accused  by  the  State. — Certain  parties  suspected  of  the  murder 
were  arrested;  four  negro  men  were  incarcerated  in  the  city  jail  charged  with  the  mur- 
der of  Narcisse  Arrieux.  Spots  of  blood  were  observed  by  the  sheriff  upon  the  coat  of 
Wilson  Childers,  a powerful  negro  man,  who  was  known  to  have  been  at  the  store  of 
Narcisse  Arrieux  on  the  night  of  the  27th.  Upon  his  arrest,  on  the  28th,  Wilson 
Childers  affirmed  that  these  spots  on  his  coat  were  caused  by  red  paint,  which  was 
rubbed  off  from  a barrel  of  whisky  which  he  had  handled  for  a merchant.  By  the  order 
of  the  court  an  examination  of  these  spots  was  made  by  physicians  and  druggists  in 
Donald  son  ville,  on  or  about  the  29tli  of  December,  1876. 

There  being  no  microscope  of  sufficient  power  in  the  town  and  its  vicinity,  the  court 
ordered  Mr.  T.  A.  Landry  to  proceed  to  New  Orleans  with  portions  of  the  coat  and 
shirt  of  the  accused  Wilson  Childers,  and  to  secure  the  services  of  a competent  chemist 
and  microscopist  for  their  careful  and  thorough  analysis.  Early  on  the  morning  of 
January  2d,  1877,  I received  the  following  note  from  Dr.  B.  F.  Gaudet,  late  President 
of  the  Board  of  Health,  State  of  Louisiana: — 

New  Orleans,  January  2d,  1877. 

Joseph  Jones,  m.d.,  Professor  of  Chemistry,  Medical  Department,  University  of  Louisiana,  New 
Orleans. 

Dear  Doctor: — Mr.  T.  A.  Landry,  of  the  Parish  of  Ascension,  has  been  appointed  custodian 
of  a sealed  package  containing  three  pieces  of  woolen  stuff  cut  from  the  coat  of  one  Wilson 
Childers,  accused  of  having,  on  Wednesday,  27th  December,  1876,  murdered  a man,  and  he  was 
ordered  to  proceed  to  New  Orleans  to  submit  the  above  to  a chemist  and  microscopist  of  well- 
known  reputation,  for  analysis  and  examination.  The  report  must  be  officially  made  to  the  Judge 
of  the  Parish.  I have,  of  course,  suggested  your  name.  You  know  that  you  must  first  take  the 
oath  before  a Justice  of  the  peace,  and  swear  to  the  report  which  you  will  prepare. 

Very  respectfully,  your  obedient  servant, 

T.  B.  Gaudet. 


506 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Result  of  Chemical  and  Microscopical  Examination  of  Stains  on  the  Coat  and  Shirt  of 
Wilson  Childers. — Upon  careful  chemical  and  microscopical  analysis  and  examination, 
I determined  that  the  stains  on  the  coat  and  shirt  of  the  accused  were  not  paint,  hut 
were  human  blood. 

I also  determined  the  fact  that  the  blood  was  that  of  a human  being  who  had  suf- 
fered and  was  probably  suffering  at  the  moment  when  the  blood  was  abstracted,  with 
malarial  or  paroxysmal  fever. 

My  written  statement  of  the  general  result  of  the  chemical  and  microscopical  analy- 
sis and  examination,  sworn  to  before  a Justice  of  the  peace,  together  with  the  pieces  of 
cloth,  carefully  sealed,  were  forwarded,  through  Mr.  T.  A.  Landry,  to  the  Honorable 
Court,  Fourth  Judicial  District,  State  of  Louisiana.  I did  not  introduce  into  this  state- 
ment any  allusion  to  the  pathological  state  of  the  blood,  but  simply  announced  these 
results,  namely: — 

1 . That  the  stains  were  not  due  to  red  paint  nor  to  any  form  of  paint. 

2.  That  the  stains  were  blood. 

3.  That  the  blood  presented  all  the  characteristics  of  human  blood. 

I informed  Mr.  Landry,  however,  of  the  conclusion  to  which  I had  arrived,  that  the 
blood  was  that  of  a human  being  who  had  suffered  and  was  suffering  at  the  moment  of 
its  abstraction,  with  malarial  or  paludal  fever. 

On  the  29th  of  June,  1877,  I received  a peremptory  summons  to  appear  in  person  in 
the  Fourth  Judicial  District  Court,  Ascension  Parish,  State  of  Louisiana,  signed  by  the 
Honorable  M.  Marks,  Judge.  I repaired  forthwith,  by  steamer  and  railroad,  to  Donald - 
sonville,  and  found  that  the  Honorable  Court  had  continued  the  case.  Subsequently,  I 
was  furnished,  by  John  H.  Ilsley,  attorney-at-law,  with  pieces  of  wood  stained  with 
blood,  cut  from  the  drawers  which  contained  the  money  of  Narcisse  Arrieux. 

Chemical  and  microscopical  analysis  showed  that  this  blood,  which  was  beyond  a 
doubt  that  of  the  deceased,  presented  the  same  pathological  change  as  that  found  on  the 
shirt  and  coat  of  Wilson  Childers,  the  accused. 

After  the  examination,  the  particles  of  wood  were  carefully  preserved  about  un- 
person. 

On  the  27th  of  May,  1878, 1 received  at  the  hands  of  the  Deputy  Sheriff,  in  the  city 
of  New  Orleans,  the  following: — 


The  State  of  Louisianna  vs.  Wilson  Childers,  et  al. 

The  State  of  Louisiana,  Parish  of  Ascension,  4th  Judicial  District  Court. 
To  Dr.  Joseph  Jones  : — 

You  are  hereby  summoned,  in  the  name  of  the  State  of  Louisiana,  to  appear  before  the  4th 
Judicial  District  Court  of  the  Parish  of  Ascension,  on  the  29th  day  of  May,  in  the  year  of  our 
Lord  1878,  at  10  o’clock,  A.  m.,  to  testify  the  truth,  according  to  your  knowledge,  in  a certain  case 
now  pending  before  this  Court,  in  which  the  State  of  Louisiana  is  plaintiff,  and  Wilson  Childers, 
et  al,  is  defendant;  and  hereof  fail  not,  under  penalty  of  the  Law. 

Witness  the  Honorable  II.  D.  Duffel,  Judge  of  said  Court,  23d  day  of  May,  187S. 

L.  E.  Bentley,  Clerk  of  said  Court. 

In  accordance  with  this  summons,  I appeared  in  the  4th  District  Court,  Parish  ol 
Ascension,  Wednesday,  May  29th,  but  I was  not  placed  upon  the  witness  stand  until 
9 o’clock,  Friday  night,  May  31st.  Through  the  courtesy  of  the  accomplished 
clerk  of  the  court,  Mr.  L.  E.  Bentley,  I was  furnished  with  the  following  report  of  my 
testimony  as  elicited  by  the  examination  of  the  State,  represented  by  D.  B.  Earhart,  Dis- 
trict Attorney,  and  R.  N.  Sims,  Edward  N.  Pugh  and  John  H.  Ilsley,  Jr.,  Attorneys- 
at-Law,  and  of  the  defence  as  conducted  by  Col.  Winchester,  of  St.  James.  In  the  fol- 
lowing report,  the  questions  propounded  by  the  State  as  plaintiff  are  indicated  by  the 
letter  S,  those  by  the  defence,  for  the  prisoner,  by  the  letter  D,  and  the  answers  which 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  507 


I returned  relating  to  the  chemical  and  microscopical  examination  of  the  blood  found 
upon  the  clothing  of  the  prisoner,  in  the  house  of  Mr.  Narcisse  Arrieux,  by  the  letter  J. 
The  counsel  for  the  State,  after  a minute  examination  as  to  the  time  which  I had 
practiced  medicine,  and  devoted  special  attention  to  the  chemical  and  microscopical 
examination  of  the  blood  of  animals  and  man,  proceeded: — 

Examination  on  Part  of  State  of  Louisiana. — S. — Was  a sealed  package,  containing 
particles  of  a coat  and  shirt,  at  any  time  delivered  to  you  officially  by  this  Court  for 
chemical  analysis  and  microscopical  examination  ? 

J. — On  or  about  the  2d  of  January,  1877,  a small  sealed  package  containing  particles 
or  pieces  of  cloth,  was  delivered  into  my  hands,  with  an  official  warrant  for  a chemical 
analysis  and  microscopical  examination,  signed  by  Judge  Marks,  of  this  Honorable 
Court. 

S. — Is  the  following  communication  to  this  Court  in  your  handwriting  ? Is  the  sig- 
nature appended  yours?  If  so,  read  the  communication  to  the  Honorable  Court. 

J. — The  report  is  in  my  handwriting,  and  the  signature  is  genuine.  The  paper  reads 
as  follows: — 

Medical  Department,  University  op  La., 

New  Orleans,  January  2d,  1877. 

On  the  2d  of  January,  1877,  a sealed  package  was  placed  in  my  hands  by  L.  A.  Landry,  act- 
ing under  the  order  of  M.  0.  Marks,  Parish  Judge,  of  the  Parish  of  Ascension.  Upon  breaking 
the  seal,  two  smaller  packages  were  found,  namely,  one  marked  “ from  left  sleeve  of  coat,”  con- 
taining two  pieces  of  cloth;  the  other  marked  “from  left  breast,”  containing  three  pieces  of  cloth. 
The  said  pieces  of  cloth  contained  spots  of  a red  and  brownish-red  color.  Careful  microscopical 
and  chemical  examinations  showed  that  the  textures  of  the  cloth  in  the  discolored  portions  have 
been  saturated  with  blood.  The  colored  and  colorless  corpuscles  were  distinctly  seen  under  a 
magnifying  power  of  420  diameters.  The  colored  and  colorless  corpuscles  resembled  in  size  and 
structure  those  of  man.  Haematin  and  albumen  were  also  present  in  the  matters  extracted  from 
the  discolored  spots.  Joseph  Jones,  m.d. 

Sworn  to  and  subscribed  before  me,  this  January  2d,  1877. 

W.  II.  Holmes,  Second  Justice  of  Peace,  Parish  of  Orleans. 

S. — Did  you  destroy  the  pieces  of  cloth  containing  the  stains  during  your  chemical 
and  microscopical  examination,  or  did  you  re-deliver  them  to  Mr.  Landry,  duly  sealed  ? 

J. — I carefully  preserved  the  pieces  of  cloth,  and,  after  sealing  them  carefully, 
delivered  them  to  Mr.  L.  A.  Landry,  in  the  presence  of  Wm.  H.  Holmes,  Second  Jus- 
tice of  the  Peace,  Parish  of  Orleans. 

S. — Can  you  identify  this  package,  with  its  seal,  direction  and  contents? 

J. — I can;  the  direction  is  in  my  handwriting;  the  seal  is  mine;  the  particles  of 
cloth  resemble  in  all  respects  those  which  were  delivered  to  me  by  Mr.  Landry,  and 
which  I examined  in  my  laboratory,  on  or  about  the  2d  of  January,  1877. 

S. — Did  the  pieces  of  cloth,  when  delivered  to  you  by  Mr.  Landry,  contain  any 
spots,  or  present  anything  peculiar? 

J.  — They  did.  Each  piece  of  cloth  contained  spots  of  a red  and  reddish-brown 
color. 

S. — Were  these  spots  caused  by  red  paint? 

J. — They  were  not  caused  by  paint  of  any  color  or  description. 

S. — How  would  you  detect  spots  of  paint  on  any  texture,  as  cloth  or  clothing? 

J. — Paint  consists  of  oil  mixed  with  metallic,  earthy  or  vegetable  or  animal  sub- 
stances, according  to  the  nature  of  the  paint  and  the  purposes  to  which  it  is  applied. 
The  oil  may  be  extracted  from  paint  by  certain  agents,  as  sulphuric  ether  and  sulphuret 
of  carbon.  The  oil  may  be  recognized  by  its  physical  and  chemical  properties,  and  also 
by  the  presence  of  globular  masses  of  various  sizes,  under  the  microscope.  The  color- 
ing matters  of  paint,  under  the  microscope,  as  a general  rule,  present  a granular  appear- 


508 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ance,  and  in  no  kind  of  paint  do  they  resemble  the  colored  blood  corpuscles  of  man  and 
animals.  In  the  case  of  red  paint,  some  form  of  the  oxide  of  iron,  or  the  oxide  of  lead, 
or  the  sulphuret  of  mercury  (vermillion)  may  be  used.  After  the  extraction  of  the  oil 
from  the  paint  by  sulphuric  ether,  these  oxides  specified  may  be  rendered  soluble  by 
the  action  of  the  mineral  acids,  and  especially  by  hydrochloric  and  nitric  acids.  The 
solutions  thus  obtained  may  be  subjected  to  several  tests.  The  salts  of  iron  give  blue 
and  bluish-green  precipitates  with  ferricyanide  and  ferrocyanide  of  potassium,  and 
black  with  solution  of  tannic  acid,  and  the  per-salts  of  iron  give  a brownish-red  precipi- 
tate with  aqua  ammonia,  and  a deep  red  color  with  sulpho-cyanide  of  potassium.  If 
the  color  of  the  paint  be  due  either  to  the  oxide  or  the  sulphuret  of  mercury,  after  the 
abstraction  of  the  oil  in  the  manner  specified,  the  metallic  mercury  may  be  reduced  by 
heat,  or  a nitrate,  sulphate  or  chloride  formed  by  the  action  of  the  respective  acids,  and 
the  soluble  salt  thus  formed  may  be  subjected  to  various  reagents,  as  iodide  of  potas- 
sium (green  precipitate  with  proto-salt  of  mercury,  and  red  precipitate  with  per-salt  of 
this  metal) ; lime  water  and  solution  of  potassa,  black  precipitate  with  proto-salt  and 
yellowish  red  with  per-salt;  a plate  of  polished  copper  plunged  in  solution  of  soluble 
salt  of  mercury  is  quickly  coated  with  metallic  mercury,  which  may  be  removed  by 
sublimation,  dissolved  in  the  mineral  acids  and  subjected  to  the  test  just  specified.  If 
the  color  be  due  to  the  red  oxide  of  lead,  the  metal  may  be  reduced  from  the  paint  by 
means  of  the  blowpipe;  the  oxide  may  also  be  separated  from  the  oil  and  subjected  to 
the  action  of  nitric  acid,  and  the  solution  subjected  to  the  action  of  various  chemical 
reagents,  as  iodide  of  potassium  (yellow  iodide  of  lead),  chromate  of  potassa  (yellow 
chromate  of  lead),  sulphureted  hydrogen  (black  sulphuret  of  lead),  sulphuric  acid  and 
soluble  sulphate  of  lead  (white  sulphate  of  lead). 

S — What  did  you  determine  these  spots  to  be  by  chemical  and  microscopical  exami- 
nation ? and  state  fully  to  this  Honorable  Court  the  ground  upon  which  your  statement 
was  based,  and  the  processes  by  which  you  arrived  at  your  conclusions. 

J. — Chemical  and  microscopical  examination  showed  the  spots  to  be  those  of  blood. 
The  presence  of  blood  was  determined  by  the  following  processes  and  reagents : When 
the  stains  were  examined  in  a strong  light,  with  a low  power  of  the  microscope, 
the  fibres  were  not  merely  colored,  but  presented  a shining,  glossy  appearance, 
and  the  individual  fibres  were  observed  to  be  invested  with  portious  of  dried 
coagulum  or  clot.  Certain  chemical  processes,  as  the  following,  established  pre- 
sumptively that  the  matter  which  imparted  the  color  to  the  spots  on  the  clothing 
of  the  accused  was  blood. 

It  readily  combined  with  cold  distilled  water,  forming  a bright  red  solution.  This 
color  was  not  changed  to  a crimson  or  a green  tint  by  a few  drops  of  a weak  solution  of 
ammonia,  but  when  this  agent,  in  concentrated  form  and  large  amount,  was  added,  the 
red  liquid  acquired  a brownish  tint.  The  red  liquid  obtained  from  the  particles  of  blood 
in  the  textures  of  the  cloth,  by  means  of  cold  water,  coagulated  when  it  was  boiled, 
the  color  was  destroyed  and  a muddy  brown,  fiocculent  precipitate  was  formed.  When . 
the  coagulum  was  collected  on  a filter  and  dried,  it  formed  a black  resinous  substance, 
quite  insoluble  in  water,  but  readily  dissolved  by  boiling  caustic  potash,  forming  a 
solution  which  was  of  a greenish  color  by  reflected,  and  reddish  by  transmitted  light. 
When  the  solution  of  the  clots  in  cold  water  was  subjected  to  the  action  of  strong  nitric 
acid,  the  red  coloring  matter  of  the  blood  and  its  albumen  were  coagulated  and  a dirty 
brown  precipitate  was  thrown  down.  When  examined  under  the  microscope  with 
various  powers,  ranging  from  400  to  1800  diameters,  the  red  matter  causing  red  stains 
was  found  to  consist  of  numerous  circular,  disc-like  or  flattened  globules,  barfing  an 
average  diameter  of  au  iuch.  The  white  or  colorless  corpuscles  of  the  blood 

were  also  clearly  distinguished. 

S. — Did  you  observe  anything  which  would  indicate  the  state  of  the  health  of  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  509 


individual  from  whom  the  blood  had  issued  upon  the  clothes  of  the  accused  ? and  if  so 
state  your  observations  to  this  Honorable  Court. 

J. — I observed  changes  in  the  blood  obtained  from  the  pieces  of  cloth  which  led 
me  to  infer  that  the  person  from  whom  it  was  abstracted  had  suffered  and  was  most 
probably  at  that  time  suffering  with  paroxysmal,  paludal  or  malarial  fever. 

This  opinion  was  based  chiefly  upon  the  following  abnormal  substances  observed  in 
connection  with  the  colored  and  colorless  or  white  blood  corpuscles  : Black  pigment 
or  melanaemic  corpuscles,  varying  from  T^o trw  t0  T'ffW  °f  an  >uch  in  diameter;  con- 
glomerations of  these  melanaemic  particles,  in  masses  of  various  sizes;  colorless  corpus- 
cles or  leucocytes  which  contained  small  granular  masses  of  black  pigment.  Many  of 
the  particles  of  the  melanaemic  pigment  were  spherical,  others  irregular  and  angular, 
some  entirely  free,  others  incased  in  a hyaline  mass;  others  incorporated  with  cellular 
elements  which  are  more  or  less  related  to  the  white  corpuscles  of  the  blood.  These 
black  pigment  particles  indicated  the  destruction  or  alteration  of  the  blood  corpuscles 
and  the  escape  of  the  haematin  of  the  red  globules  which  is  characteristic  of  malarial 
fever. 

(S. — How  long  have  you  been  engaged  in  the  microscopical  and  chemical  investiga- 
gation  of  the  blood  of  man  in  disease,  and  upon  what  facts  do  you  base  the  preceding 
statement  ? 

J.  — My  investigations  upon  the  chemical  and  microscopical  changes  of  the  blood  in 
fevers,  aud  especially  in  malarial  and  yellow  fevers,  were  commenced  iu  1856,  and  have 
been  pursued  continuously  up  to  the  present  moment ; and  during  the  past  ten  years  I 
have  treated,  in  the  wards  of  the  Charity  hospital  of  New  Orleans,  over  four  thousand 
cases  of  various  diseases,  more  than  one-half  of  which  were  due  to  the  action  of  the 
malaria  of  the  swamps  and  marshes  of  the  Mississippi  valley.  The  blood  in  a large 
number  of  these  cases  has  been  subj ected  to  microscopical  and  chemical  examination, 
and  in  fatal  cases  post-mortem  examinations  performed.  The  result  of  these  investiga- 
gations,  which  throw  light  upon  the  inquiries  of  this  Honorable  Court,  are  as  follows: 

1.  The  malarial  poison  produces  profouuder  alterations  and  more  rapid  destruction 
of  the  colored  blood  corpuscles  than  any  other  known  febrile  agent. 

2.  The  destruction  of  the  colored  corpuscles  takes  place  chiefly  in  the  spleen  and 
liver. 

3.  The  black  pigment  resulting  from  this  haematin  of  the  blood  corpuscles  is  fre- 
quently observed  in  the  blood  as  it  circulates  in  the  vessels  and  capillaries,  in  masses  of 
various  sizes  and  in  the  form  of  cellular  elements. 

4.  The  black  pigment  is  deposited  in  the  capillaries  of  various  organs  and  tissues, 
as  those  of  the  liver,  medulla  of  the  bone,  brain  and  subcutaneous  tissue. 

5.  The  peculiar  sallow,  greenish-yellow  and  bronzed  hue,  which  characterizes  those 
who  have  been  for  a length  of  time  subjected  to  the  prolonged  action  of  the  malarial 
poison  or  to  its  powerful  action  in  pernicious  remittent  fever  and  in  malarial  haematuria, 
is  due  not  merely  to  hepatic  and  splenic  derangement,  but  also  to  the  deposit  of  pig- 
ment particles  in  the  subcutaneous  capillaries. 

S. — Did  you  make  any  further  examinations  of  blood  in  this  case  or  in  connection 
with  the  deceased?  If  so,  state  the  result. 

J. — I examined  bits  of  wood  brought  to  New  Orleans,  and  placed  in  my  hands  by 
John  H.  Ilsley,  attorney-at-law  and  counsel  for  the  State.  These  pieces  of  wood,  the 
one  of  cedar  and  the  other  of  mahogany,  were  spotted  and  coated  upon  the  smooth  side 
with  blood.  Microscopical  and  chemical  examination  revealed  that  it  was  human 
blood,  and  human  blood  presenting  similar  pathological  alterations  to  that  examined 
on  the  particles  of  cloth  cut  from  the  coat  and  shirt  of  the  prisoner,  and  previously 
described.  The  blood,  as  in  the  first  examination,  contained  numerous  black  particles, 
and  pigment  cells  and  colorless  corpuscles,  containing  round,  black  pigment  particles. 


510 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Upon  arriving  in  Donaldsonville,  through  the  kindness  of  Dr.  John  E.  Duffel,  I visited 
the  house  formerly  occupied  by  the  deceased,  and  found  that  the  particles  of  wood  fitted 
exactly  into  the  front  portions  of  two  drawers  belonging  to  two  desks.  Undeniable 
testimony  established  the  fact  that  the  blood  on  these  pieces  of  wood  was  that  from  the 
deceased  after  the  infliction  of  the  blows  on  the  head. 

S. — Have  you  preserved  these  pieces  of  wood?  and  if  you  have,  produce  them 
before  the  jury  and  fit  them  into  the  places  from  whence  they  were  cut,  in  the  drawers, 
which  have  been  brought  to  this  Court. 

J. — I have  carefully  preserved  the  pieces  of  wood  upon  my  person,  from  their  first 
reception  to  the  present  time.  They  correspond  exactly  to  the  missing  portions  of 
wood  in  the  drawers  exhibited  by  the  State  before  this  Honorable  Court. 

S. — Have  you  examined  the  blood  of  various  animals,  as,  for  instance,  reptiles,  birds, 
and  domestic  animals?  And  if  you  have,  state  the  general  results  of  your  examinations, 
and  if  the  blood  of  these  animals  can  be  distinguished  from  that  of  man. 

J. — I have  examined  microscopically  and  chemically  the  blood  of  a large  number  of 
the  indigenous  fish,  amphiuma,  sirens,  batrachians,  ophidians,  saurians,  birds  and  wild 
mammalia,  and  also  the  blood  of  domestic  fowls  and  animals,  and  can  state  that  in  fish,* 
amphibians,  batrachians,  saurians  and  birds,  the  blood  corpuscles  can  be  distinguished 
at  once  and  beyond  all  question  under  the  microscope,  on  account  of  the  elliptical  shape 
and  nucleated  centre  ; but  in  the  case  of  the  domestic  and  indigenous  mammalia  a more 
critical  examination  is  required  ; for  in  this  class  of  animals  the  size  of  the  globules 
varies  within  comparatively  narrow  limits  ; they  have  a flattened  or  disc-like  form,  and 
with  the  exception  of  the  camel  tribe,  the  outline  of  the  disc  is  circular. 

Examination  on  the  part  of  the  Defence. — D. — Are  you  absolutely  certain  that  the 
stains  on  the  pieces  of  cloth  placed  in  your  hands  for  microscopical  and  chemical 
analysis  were  caused  by  human  blood  ? 

J. — The  substances  causing  the  stains  presented  all  the  chemical  and  microscopical 
properties  of  human  blood,  and  blood  presenting  a special  pathological  alteration. 

D. — Can  you  by  means  of  chemical  and  microscopical  examination  of  the  blood 
determine  any  form  of  disease  ? 

J. — By  chemical  and  microscopical  examination  I am  not  able  to  determine  every 
form  of  disease. 

D. — You  would  then  be  in  doubt  concerning  the  result,  in  certain  diseases,  of  the 
chemical  and  microscopical  examination  ; please  state,  therefore,  if  there  are  any 
diseases,  the  nature  of  which  may  be  revealed  by  the  microscope? 

J. — The  microscope  enables  us  to  distinguish  clearly  the  changes  induced  in  the 
blood  by  malarial  fever.  That  condition  of  the  blood  known  as  leucocythsemia  or 
leukaemia  can  be  accurately  determined  by  microscopical  examination.  There  was  no 
doubt  in  my  mind  that  the  blood  examined  was  human  blood,  from  one  who  had  suf- 
fered, and  perhaps  was  at  the  time  suffering  with  malarial  fever. 

* The  blood  discs  of  fishes  are  commonly  of  a full,  elliptic  shape  ; they  present  the  largest  size  ' 
in  the  sharks,  but  are  smaller  in  them  in  proportion  to  the  body  or  mass  of  blood  than  in  the 
batrachia.  The  white  corpuscles  are  in  less  proportion  in  the  blood  of  fishes  than  in  saurians, 
birds  or  mammals.  In  my  physiological  and  chemical  researches,  published  by  the  Smithsonian 
Institution  in  1856,  I endeavored  to  establish  the  comparison  of  main  physiological  importance 
between  the  blood  in  different  groups  of  vertebrates,  namely,  that  which  relates  to  the  proportion 
of  the  organic  matters  contained  in  tho  water.  It  was  then  clearly  shown  that  tho  blood  varied, 
in  the  different  classes  of  animals,  in  physical  and  chemical  properties.  Tho  blood  of  reptiles  has 
red  corpuscles  of  a flattened,  sub-biconvex,  elliptical  shape,  proportionally  smallest  in  ophidia, 
roundest  in  chelonia,  and  largest  in  batrachia.  In  birds  the  blood  discs  are  moro  abundant  than 
in  tho  cold-blooded  vertebrates;  they  are  nucleated,  elliptic  and  flattened  in  form,  averaging  in 
size,  in  long  diameter  jita  to  3^3  of  an  inch. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  511 


D. — What  did  you  say  was  the  average  size  of  the  colored  blood  corpuscles  in  the 
stains  upon  the  cloth?  and  while  giving  this  measurement,  give  those  also  of  the  dog, 
horse,  rat,  cat,  rabbit,  ass,  ox,  cow,  sheep  and  goat. 

J. — The  average  of  the  diameter  of  the  blood  corpuscles  from  the  stains,  was  about 
■jsVcr  °f  an  inch.  The  corpuscles  of  human  blood  are  larger  than  those  of  domestic 
animals.  Thus,  the  average  diameter  in  the  dog  is  about  of  an  inch  ; horse, 
°f  an  inch  ; in  the  rat,  ^ of  an  inch  ; in  the  cat,  T:fl j,  o °f  au  inch  ; in  the 
rabbit,  jo'nt)  of  an  inch  ; in  the  ass,  of  an  inch  ; in  the  ox,  of  an  inch  ; 

in  the  cow,  of  an  inch  ; in  the  pig,  T j jj-  of  an  inch ; in  the  sheep, 

tof  an  inch  ; in  the  goat,  of  an  iuch. 

D. — Do  not  those  individual  blood  corpuscles  in  man  and  animals  vary  in  their 
diameter  in  the  same  specimen  of  blood?  and  if  so  state  to  the  Honorable  Court  the 
causes  of  these  variations. 

J. — The  blood  corpuscles  of  man  and  animals  vary  in  their  diameters  within  cer- 
tain limits;  thus,  those  of  man  may  vary  from  to  j-gso',  of  the  dog  from  to 
Wtroi  the  hare  from  to  ; in  the  ox  from  to  the  sheep  from 

TT3T  to  gjjVo  of  an  inch. 

D. — Difficulty,  therefore,  exists  in  distinguishing  between  the  blood  of  man  and 
domestic  animals;  and  in  view  of  this  fact  do  you  assert  absolutely  that  the  stains  in 
the  pieces  of  cloth  were  human  blood  ? 

J. — I admit  that  difficulties  exist  in  such  examinations.  I affirmed  that  the  human 
blood  corpuscles,  upon  an  average,  were  larger  than  that  of  the  domestic  animals 
named.  I also  affirmed  that  the  stains  upon  the  pieces  of  cloth  presented  all  the  char- 
acteristics of  human  blood.  I went  a step  further  and  affirmed  that  this  blood  pre- 
sented pathological  appearances  which,  as  far  as  my  investigations  extend,  are  peculiar 
to  human  blood  in  a certain  diseased  state,  and  that  I have  never  observed  such  a con- 
dition in  the  blood  of  animals;  and  that  the  blood  from  the  house  in  which  the  deceased 
was  murdered  presented  similar  chemical  and  microscopical  characters. 

D. — Can  the  colored  blood  corpuscles  be  detected  with  accuracy  in  dried  blood  ? 

J- — They  can  he  detected  in  many  cases;  aud  they  were  detected  accurately  in  the 
case  now  before  this  Honorable  Court. 

D. — Can  you  distinguish  between  the  blood  of  a woman  and  the  blood  of  a man  ? 
J. — I cannot. 

D. — Can  you  distinguish  the  blood  of  a foetus  from  the  blood  of  its  mother  ? 

J. — I cannot. 

D. — Can  you  distinguish  the  blood  of  the  different  races  of  men  ? for  example,  can 
you  chemically  and  microscopically  distinguish  the  blood  of  a white  man  from  that  of 
a negro  ? 

J. — Different  races  are  said  to  have  distinct  odors;  sulphuric  acid  applied  to  blood 
will  liberate  the  peculiar  odor  of  the  animal;  I have,  upon  many  cases,  satisfied  myself 
of  the  possibility  of  developing  the  peculiar  odor  of  the  blood  in  different  animals  by 
sulphuric  acid.  I cannot,  however,  speak  positively  with  reference  to  the  blood  of  the 
different  races  of  mankind. 

VERDICT  OF  JURY. 

By  the  testimony  of  several  witnesses,  two  of  whom  were  practicing  physicians,  it 
was  clearly  established  that,  for  some  weeks  before  and  up  to  the  time  of  his  murder, 
Narcisse  Arrieux  was  suffering  with  intermittent  malarial  fever  (chills  and  fever).  The 
judgment  of  the  jury  rested,  to  a great  degree,  upon  the  presence  of  blood  on  the 
clothing  of  the  accused,  Wilson  Childers. 

We  have  been  informed  by  John  H.  Ilsley,  Jr.,  one  of  the  attorneys  for  the  prosecu- 
tion, that  an  important  witness  testified  as  to  the  guilt  of  the  four  negroes  accused  of 


512 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


the  murder  of  Narcisse  Arrieux.  The  jury  rendered  the  verdict  guilty  of  murder,  with 
capital  punishment. 

MICROORGANISMS  OF  MALARIAL  FEVER. 

The  microorganisms,  which  we  have  observed  in  the  blood  of  patients  suffering 
from  malarial  fever  may  be  thus  briefly  enumerated: — 

(a)  Minute  globular  bodies,  from  the  ten-thousandth  to  the  thirty-thousandth  of  an 
inch  in  diameter,  having  the  general  appearance  and  chemical  characters  of  the  spores 
of  bacteria. 

( b ) Globular  bodies  of  larger  size  than  the  preceding,  often  of  a dark,  opaque  char- 
acter, found  not  ouly  in  the  liquor  sanguinis,  but  also  in  the  colored  blood  corpuscles 
and  in  the  colorless  blood  corpuscles.  These  bodies,  most  probably  true  spores,  possess 
the  power  of  invading  and  destroying  the  colored  blood  corpuscles.  These  micrococci 
or  spores  are  often  observed  in  the  blood  in  groups,  surrounded  by  protoplasm,  consti- 
tuting zoogloea. 

(c)  Ovoid,  cylindrical  and  rose-shaped  bodies,  not  destroyed  by  acetic  acid  and  stained 
by  aniline  dyes.  These  bodies  increase  during  the  cold  stage,  and  are  most  numerous 
in  pernicious  malarial  fever. 

( d ) Colorless  blood  corpuscles  containing  minute  pigment  granules,  and  dark  spheri- 
cal bodies,  resembling  sporules;  many  of  these  pigmented  corpuscles  or  aggregations  of 
dark  spherical  bodies,  surrounded  by  protoplasm,  are  about  twice  the  diameter  of  the 
colorless  blood  corpuscles  of  normal  blood;  and  their  behavior  under  the  action  of 
reagents  and  also  during  the  process  of  staining,  leads  to  the  view  that  a portion  at 
least  of  these  bodies  must  be  regarded  as  vegetable  organisms.  The  large  pigment 
cells  appear  to  be  characteristic  of  malarial  fever. 

(e)  Masses  of  luematin  of  various  forms,  irregular  in  size  and  shape,  but  most  gener- 
ally the  sides  and  portions  seen  in  profile  are  angular.  The  deposits  of  large  pigment 
masses  in  the  brain  in  malarial  fever,  and  especially  in  cases  of  repeated  paroxysm, 
find  their  origin  in  the  changes  of  the  colored  blood  corpuscles,  induced  by  the  morbific 
ferment  or  microorganisms  of  malarial  fever. 

There  is  an  actual  destruction  of  the  colored  blood  corpuscles  in  the  living  blood, 
and  within  the  walls  of  the  living  capillaries  and  blood  vessels  in  malarial  fever;  and 
this  destruction  is  not  referable,  either  solely  or  originally,  to  the  action  of  the  bile 
acids  accumulated  in  the  blood,  as  a consequence  of  biliary  congestion,  or  obstruction 
during  the  febrile  stages  of  malarial  fever. 

We  can  detect  the  process  of  the  disintegration  of  the  colored  blood  corpuscles  by 
the  microscope,  and  detect  the  very  inception  of  that  great  pathological  change  which 
constitutes  one  of  the  most  distinctive  features  of  malarial  fever,  and  which  must  be 
carefully  considered  in  any  scientific  and  rational  plan  of  treatment. 

(/)  Marked  variations  in  the  size  of  the  colored  blood  corpuscles. 

These  variations,  from  small  corpuscles  to  what  may  be  called  giant  corpuscles,  twice 
the  diameter  of  normal  blood  globules,  appear  to  be  characteristic  of  malarial  fever. 

The  destruction  of  colored  blood  corpuscles  does  not  take  place  with  equal  rapidity 
in  all  parts  of  the  organism,  but  appears  to  be  most  marked  in  the  spleen  and  liver. 

The  blood  pigment  resulting  from  the  haematin  of  the  blood  corpuscles  is  frequently 
observed  in  the  blood  as  it  circulates  in  the  vessels  and  capillaries,  in  masses  of  various 
sizes,  and  in  the  form  of  cellular  elements. 

Without  doubt  local  congestions  may  be  caused  by  obstruction  of  the  circulation  in 
the  capillaries  and  by  these  pigment  particles  and  cells;  and  such  congestions  may  lead 
to  local  hemorrhages.  The  congestions  and  hemorrhages  thus  resulting  are  especially 
significant  when  occurring  within  the  structures  of  the  brain  and  spinal  cord. 

The  appropriation  of  a portion  of  the  altered  coloring  matter  (haematin  of  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  513 

colored  blood  corpuscles),  by  the  leucocytes,  is  due  to  the  physical  and  vital  endow- 
ments of  their  elementary  bodies. 

It  is  now  generally  admitted  that  the  colorless  corpuscles  are  elementary  organisms 
which  are  endowed  with  the  power  of  spontaneous  motion,  this  power  belonging  to 
them  in  virtue  of  the  protoplasm  of  which  these  bodies  are  composed.  This  motion  is 
of  two  kinds,  the  change  of  form  and  the  change  of  place;  the  latter  resulting  from 
the  former.  It  has  been  demonstrated  that  the  colorless  blood  corpuscles  possess  the 
faculty  of  taking,  by  virtue  of  their  amoeboid  movements,  solid  particles  into  their 
substance. 

This  subject  is  of  transcendent  importance  to  the  student  of  fevers,  in  giving  an 
important  point  of  diagnosis  for  malarial  fever,  which  distinguishes  it  from  all  other 

! forms,  and  especially  from  yellow  fever. 

The  author  demonstrated  during  the  progress  of  his  pathological  researches,  extend- 
ing from  1856  to  1887,  the  power  of  the  colorless  corpuscles  of  human  blood  to  feed 
upon  and  appropriate  the  hiemoglobin,  hsematin  and  haemin  of  the  colored  blood  cor- 
puscles in  the  blood  vessels  of  malarial  patients,  before  physiologists  had  experiment- 
ally determined  by  employing  either  finely  divided  fatty  substances,  or  coloring 
matter,  the  power  of  the  colorless  blood  corpuscles  to  take  solid  particles  into  their 
substance. 

We  have  thus  traced  the  pigmentation  of  the  colorless  blood  corpuscles  in  malarial 
fever  to — 

(a)  The  destruction  of  the  colored  blood  corpuscles  by  the  morbific  ferment,  or 
microorganism  of  malarial  fever. 

( b )  The  separation  of  the  haemoglobin,  haemin  and  haematin,  and  its  appropriation 

Eby  the  colorless  blood  corpuscles,  in  virtue  of  their  physical  and  vital  properties  and 
amoeboid  movements. 

(c)  The  invasion  of  the  colorless  corpuscles  by  the  colored  spores  of  the  malarial 
microorganisms. 

GENERAL  RESULTS  OP  EXPERIMENTS  INSTITUTED  TO  DETERMINE  THE  NATURE  AND 
RELATIONS  OF  THE  ORGANIC  AND  LIVING  CONSTITUENTS  OF  THE  ATMOSPHERE  TO 
THE  MICROSCOPICAL  AND  CHEMICAL  CHANGES  OF  THE  BLOOD  IN  YELLOW  AND 
MALARIAL  FEVERS,  DURING  THE  YELLOW  FEVER  EPIDEMIC  IN  NEW  ORLEANS, 
LOUISIANA,  1878. 

Relying  upon  the  fact  that  cold  arrests  yellow  fever,  I sought  to  condense  and  ren- 
der palpable  to  the  eye  and  touch  the  poison,  by  passing  large  volumes  of  the  yellow 
fever  atmosphere  of  1878  through  ice  and  ice-cold  water,  by  means  of  carefully  con- 
structed bellows.  In  this  manner  I threw  from  100,000  to  600,000  cubic  centimetres 
of  the  yellow  fever  air  of  1878  through  ice  and  ice-cold  water.  The  products  of  the 
condensation  thus  obtained  were  examined,  both  chemically  and  microscopically.  The 
air  was  taken  from  rooms  in  the  most  infected  localities  containing  those  suffering  with 
the  various  stages  of  yellow  fever. 

I also  endeavored  to  determine  whether  the  living  particles  found  in  the  air  differed 
in  accordance  with  the  locality,  whether  malarious  or  non-malarious.*  After  a thorough 
examination  of  the  minute  spores,  micrococcci  and  organic  and  inorganic  matters  of  the 
air  in  which  yellow  fever  was  prevailing,  it  was  observed — 

(a)  In  the  well-paved  and  well-drained,  non-malarious  portions  of  New  Orleans,  the 
solid  matters  of  the  air  examined,  not  only  during  the  prevalence  of  the  yellow  fever, 


* “ Yellow  Fever  Epidemic  of  1878,  New  Orleans,”  by  Joseph  Jones,  M.n.  Next)  Orleans  Med- 
ical and  Surgical  Journal,  March,  1879,  pp.  683-715  ; April,  1879,  pp.  763-780;  May,  1879,  pp. 
852-879  ; June,  1879,  pp.  933-942. 

Vol.  IV— 33 


514 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


but  also  at  various  intervals  during  a period  of  six  to  eight  months,  I discovered  no 
form  which  could  he  referred  to  such  microscopical  plants  as  the  chlorococcum  vulgare, 
protococcus  viridis,  palmella  cruenta,  coccochloris  brebinonii  and  other  coufervoidae, 
or  unilocular  algae  capable  of  producing  chlorophyl. 

Certain  granular  cells  observed  in  the  blood  of  malarial  fever  resemble  most  nearly 
the  resting  spore  of  bulbochaete  intermedia,  and  the  granular  cells  of  palmella  cruenta  ; 
but  no  such  cells  were  observed  in  the  atmosphere  of  the  houses  situated  in  well-paved 
and  well-drained  sections  of  the  city. 

The  forms  of  the  non-malarial  sick  rooms  (rooms  containing  yellow  fever  patients) 
were  referable  to  those  most  nearly  connected  with  putrefaction  and  fermentation, 
as  the  bacteria  and  torulae,  penicillus  and  micrococci  and  cryptoeoccse. 

The  absence  of  any  of  the  known  forms  of  algae  in  the  air  of  yellow  fever  collected 
in  the  non-malarious,  well-drained  and  well-paved  portions  of  the  city  of  New  Orleans, 
is  important,  in  that  this  class  of  plants  is  thus  excluded  from  the  consideration  of  the 
question  relating  to  the  origin  and  causation  of  yellow  fever. 

( b ) The  water  obtained  by  passing  the  air  through  ice  and  melting  ice  and  ice-cold 
water,  was  preserved,  and  portions  added  to  solutions  of  sugar.  The  water  from  the 
rooms  in  which  yellow  fever  patients  lay  caused  the  development  in  solution  of  sugar 
of  a delicate  fungus,  the  spores  of  which  were  distributed  in  regular  rows,  within  the 
thallus.  This  plant,  as  well  as  that  developed  in  the  yellow  fever  blood,  assumed  a 
distinct  yellow  color.  Both  penicillium  and  torn  lie  were  observed  in  these  solutions. 

For  many  years  we  have  had,  and  taught  essentially,  the  following — 

THEORY  OF  THE  CAUSATION  OF  THE  PATHOLOGICAL  PHENOMENA  IN  THE  LIVING 
HUMAN  BEING,  KNOWN  AS  MALARIAL  FEVER. 

We  are  justified  by  our  own  observations,  as  well  as  those  of  observers  who  have 
recorded  positive  results,  in  the  conclusion  that  malarial  fever  is  caused  by  a specific 
living,  pathogenic  microorganism. 

This  microorganism  and  its  spores  exist  in  the  soil,  waters  and  atmosphere  of  mala- 
rial regions.  It  gains  access  to  the  blood  of  human  beings,  where  it  commits  its  greatest 
ravages,  through  the  lungs  and  through  the  skin  and  alimentary  canal,  but  it  is  chiefly 
through  the  respired  air  and  the  ingested  water  that  it  finds  the  media  for  its  penetra- 
tion into  the  capillaries  and  circulatory  fluids. 

The  condition  of  the  individual  at  the  time  of  exposure,  whether  of  health  or  ill- 
health,  and  the  integrity  of  the  pulmonary,  alimentary  and  cutaneous  surfaces,  without 
doubt  modify  or  influence  the  rapidity  of  the  introduction  and  the  subsequent  action  of 
the  malarial  pathogenic  microorganism.  After  the  introduction  of  the  pathogenic 
microorganisms  into  the  circulation  they  cause  the  splitting  up  of  complex  nitrogenous 
compounds  (proteids,  colloids,  as  well  as  crystalloid  bodies)  into  compounds  of  compar- 
atively low  or  simple  composition;  they  cause  the  disintegration  of  nitrogenous  com- 
pounds by  withdrawing  from  the  compounds  certain  molecules  of  nitrogen,  building 
up  with  these  their  own  protoplasm.  Similarly  carbohydrates  and  inorganic  salts  are 
dissociated  by  them,  inasmuch  as  they  require  a certain  amount  of  carbon,  phosphorus 
and  potassium  for  building  up  their  own  bodies.  The  profound  and  remarkable 
changes  of  the  amount  and  character  of  the  constituents  of  the  blood  and  urine,  which 
we  have  detailed  in  the  preceding  pages,  are  thus  shown  to  have  their  origin  in  the 
chemical  changes  excited  by  the  life  acts  of  the  pathogenic  malarial  microorganism. 
In  this  process  of  decomposition,  certain  alkaloid  bodies,  closely  related  to  the  ptomaines, 
are  produced  and  act  upon  the  ganglionic  centres  of  the  nervous  system,  indicating 
aberrated  nervous  and  muscular  action,  causing  capillary  congestion,  deranged  secre- 
tion and  other  toxic  effects.  It  is  probable  that  in  the  most  malignant  cases  a compound 
or  compounds  resembling  the  septic  poison  (sepsiu)  is  one  of  the  products  of  decompo- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


515 


sition  of  animal  substances.  It  will  be  readily  admitted  that  putrid  intoxication 
or  poisoning  may  occur  as  a pyaemic  affection  in  the  human  subject,  when  a large  ulcer- 
ating surface  exists,  in  which  it  is  well  known  that  large  numbers  of  putrefactive 
organisms  are  growing  and  are  producing  the  septic  poison  or  sepsin,  which  can  be 
isolated  by  various  chemical  processes  destructive  of  every  living  microorganism.  Gas- 
pard,  Burdon-Sanderson,  Panum,  Bergmann,  Billroth,  Guttmann,  Semmer  and  many 
others,  have  shown  that  sepsin  injected  into  the  vascular  system  of  animals  produces  a 
marked  febrile  rise  of  temperature,  and  is  capable  of  causing  death  with  the  symptoms 
of  acute  poisoning,  showing  vomiting  and  purging,  spasms,  torpor,  collapse  and  death. 
On  post-mortem  there  are  found  changes  similar  to  those  observed  in  the  most  malig- 
nant of  fevers,  and  especially  of  hemorrhagic  malarial  fever  and  yellow  fever;  namely, 
severe  congestion  and  hemorrhage  of  the  stomach,  duodenum  and  rectum ; hemorrhage 
iu  the  pleura,  lungs,  pericardium  and  endocardium;  congestion  and  hemorrhage  in  the 
peritoneum;  congestion  of  the  liver;  congestion  of  the  kidneys  and  bloody  urine.  This 
putrid  infection  leads  to  death  in  twelve  to  twenty-four  hours,  or  even  less.  On  inject- 
ing smaller  quantities  only  a febrile  disturbance  is  noticed,  severe  symptoms  and  death 
only  following  after  injection  of  considerable  quantities,  such  as  several  centimetres,  of 
putrid  fluid.  Thus  sepsin  is  known  to  be  one  of  the  products  of  the  chemical  changes 
excited  in  nitrogenous  bodies  by  the  multiplication,  growth  and  life  actions  of  septic 
bacteria. 

By  holding  that  the  microorganism  of  malarial  fever  develops  or  produces  by  its 
act  ion  on  the  proteid  and  morphological  elements  of  the  blood,  bodies  related  to  the 
animal  alkaloids  (ptomaines)  and  to  sepsin,  we  have  an  explanation  of  the  violent 
vomitings,  sudden  hemorrhages  and  profound  coma  characteristic  of  the  severest  forms 
of  malarial  disease.  At  the  same  time  it  should  be  observed  that  in  the  growth  and 
chemical  action  of  certain  microorganisms,  the  products  of  the  decomposition  started 
and  maintained  by  them  have  a most  detrimental  influence  on  themselves,  inhibiting 
their  multiplication;  in  fact,  after  a certain  amount  of  these  products  has  accumulated, 
the  organisms  become  arrested  in  their  growth,  and  finally,  may  be  altogether  killed. 
We  have  already  dwelt  upon  the  importance  of  the  fact  that  indol,  skatol,  phenol , and 
other  bodies  belonging  to  the  aromatic  series,  which  are  produced  in  the  course  of 
putrefaction  of  proteids,  have  a most  detrimental  effect  on  the  life  of  many  microorgan- 
isms. While  it  has  not  been  as  yet  clearly  determined  whether  in  these  instances  the 
organisms  produce  the  chemical  effect  by  creating  a special  zymogen  or  ferment,  and 
through  it  causing  the  chemical  disturbance,  or  whether  they  merely  dissociate  the 
compounds  by  abstracting  for  their  own  use  certain  molecules  ; it  is,  on  the  contrary, 
well  established  that  in  consequence  of  this  chemical  disturbance  definite  chemical 
substances  are  produced. 

In  view  of  the  fact  that  the  microorganism  of  malarial  fever  acts  with  greatest 
energy  and  most  destructive  effects  upon  the  colored  blood  corpuscles;  and  in  view  of 
the  fact  that  there  appears  to  be  no  practical  limit  to  the  alteration  and  destruction 
of  the  red  globules;  we  must  refer  the  temporary  cessation  of  the  actions  of  the  micro- 
organism (the  intermissions  and  remissions  of  malarial  fever),  not  to  the  exhaustion  of 
any  special  chemical  substance  in  the  blood  and  organs,  but  rather  to  the  effects  of  the 
elevated  temperature  and  the  formation  of  antiseptic  compounds,  in  arresting  the 
development,  and  in  destroying  large  numbers  of  the  microorganisms.  In  certain  dis- 
eases, as  smallpox,  vaccinia  and  typhus  fever,  the  chemical  changes  resulting  from  the 
action  of  the  pathogenic  microorganisms,  as  well  as  the  elevation  of  temperature,  are 
such  as  to  cause  the  complete  destruction  and  elimination  of  the  germs  originally  pro- 
ducing the  disease. 

In  the  paroxysms  of  malarial  fever,  there  is  in  like  manner  a destruction  and  elimi- 
nation of  the  pathogenic  microorganisms,  but  in  many  cases  the  destruction  and  elimi- 


516 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


nation  of  the  germs  of  the  disease  is  not  complete,  and  these  remaining  in  the  blood 
reproduce  their  kind,  and  after  a definite  period  the  same  phenomena  are  repeated. 
The  paroxysm  of  malarial  fever,  with  its  elevated  temperature  and  antiseptic  products, 
must,  to  a certain  extent,  be  regarded  as  curative  in  its  effects  ; and  it  is  well  estab- 
lished that  a considerable  number  of  ca  es  of  malarial  fever  end  spontaneously  and 
pass  into  recovery  after  one  or  more  paroxysms,  without  the  employment  of  any  anti- 
septic or  any  remedies  whatever  ; in  such  cases  the  febrile  changes  excited  by  the 
pathogenic  organisms  have  resulted  in  their  death  and  elimination.  On  the  other  hand, 
the  most  destructive  and  incurable  forms  of  malignant  anamiia,  ending  finally  in  he- 
patic and  splenic  enlargement,  general  anasarca  and  failure  of  the  heart  and  nervous 
centres,  often  result  from  the  continuous  and  almost  unobserved  action  of  the  malarial 
microorganism  upon  the  constituents  of  the  blood,  and,  more  especially,  upon  the  col- 
ored blood  corpuscles;  in  such  cases  the  antiseptic  products  of  high  fever  have  not  been 
formed. 

We  must  look  to  chemical  knowledge  to  guide  us  in  our  contests  with  the  specific 
agents  of  malarial  and  other  diseases,  and  we  accept  the  doctrine,  with  but  slight  modi- 
fication, that  no  chemical  or  other  agent  can  be  rightly  regarded  as  disinfectants,  in 
respect  of  any  disease,  unless  it  can  be  shown  to  have  the  power  of  inhibiting  or  arrest- 
ing the  development  and  growth  of  the  particular  species  of  microphyte  which  is  the 
constant  concomitant  of  the  morbid  process  ; and  that  inasmuch  as  all  specific  micro- 
phytes are  endowed  with  the  power  of  multiplying  in  the  blood  and  living  tissues  of 
the  organism  they  infest,  and  of  there  playing  their  part  in  the  morbid  process ; all 
specific  disinfectants  must,  in  order  to  encounter  the  organisms  they  are  intended  to 
destroy,  be  of  such  a nature  that  they  can,  without  prejudice,  be  mixed  with  the  circu- 
lating blood,  and  come  into  direct  contact  with  the  tissues. 

In  the  case  of  malarial  fever  we  have  in  quinine  such  a disinfectant,  which  is  not 
only  poisonous  to  the  pathogenic  microorganism  of  malarial  fever  but  is  also  of  such  a 
nature  that  it  can,  without  prejudice,  be  mixed  with  the  circulating  blood  and  come 
into  direct  contact  with  the  tissues.  Quiuia  may  be  taken  in  large  doses  without 
dauger ; it  is  eliminated  slowly,  with  little  or  no  change,  by  the  skin  and  kidneys  ; it 
circulates  freely  in  the  blood,  and  passes  into  the  organs,  and  is  thus  brought  into  con- 
tact with  all  pathogenic  microorganisms;  its  action  as  a disinfectant  is  greatly  increased 
by  the  rapidity  of  the  circulation,  and  its  action  is  also  favored  and  supplemented  by 
the  antiseptic  products  developed  during  the  febrile  paroxysms.  Professor  Ceri,  of 
Camerino,  has  shown  that  the  infecting  power  of  the  organisms  of  malarial  soils  by  the 
introduction  of  quinine  into  the  infecting  fluids,  one  part  of  quiuia  to  800  of  the  cul- 
ture fluids,  prevented  the  development  of  the  malarial  spores,  and  arrested  the  putrid 
fermentation  induced  by  them.  Administered  to  healthy  men,  quinine  reduces  the 
urea  twenty-five  per  cent,  and  the  sulphuric  acid  forty  per  cent.;  it  diminishes  the 
amount  of  uric  acid;  it  slightly  increases  the  amount  of  water;  it  does  not  diminish 
the  amount  of  carbonic  acid  excreted  by  the  lungs.  The  spleen  of  warm-blooded  ani- 
mals contracts  under  the  influence  of  quiuia  within  a few  hours  ; it  becomes  tougher 
and  its  surface  is  thrown  into  folds;  these  phenomena  are  not  prevented  by  the  previous 
section  of  the  afferent  nerves.  In  healthy  persons  and  in  most  febrile  patients,  it  is 
not  decomposed  in  passing  through  the  blood,  but  is  entirely  excreted  by  the  kidneys 
and  bowels;  notwithstanding  that  it  does  not  directly  take  part  in  the  chemical  changes 
in  the  body,  it  produces  giddiness  and  ringing  in  the  ears,  disturbances  of  hearing  and 
vision,  depression  of  reflex  irritability,  depression  or  impairment  of  the  heart’s  action  ; 
diminished  frequency  of  the  pulse;  diminished  arterial  pressure,  prostration  and  reduc- 
tion of  animal  temperature.  Solutions  of  albumen  are  converted  into  peptones  if 
shaken  up  in  an  atmosphere  of  nascent  oxygen,  but  this  change  is  prevented  if  quiuia 
be  present.  Even  in  relatively  small  quantities  it  prevents  the  putrefaction  of  nitro- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  517 


gencus  substances,  as  well  as  several  simpler  fermentive  processes,  in  both  cases  it  acts 
directly  on  the  protoplasm  of  which  the  substances  or  their  germs  are  composed.  On 
the  other  hand  it  is  of  importance,  in  the  administration  of  quinine  in  large  or  continu- 
ous doses,  that  other  amorphous  ferments,  such  as  ptyalin  and  pepsin,  have  tlieir  prop- 
erties very  slightly  or  not  at  all  arrested  by  quinia,  and  there  are  several  protoplasmatic 
organisms  on  which  it  has  no  poisonous  effects  whatever,  whereas  it  reacts  on  the  other 
with  unexpected  vigor. 

The  poisonous  action  of  many  putrid  fluids  upon  warm-blooded  animals  may  be 
neutralized,  either  completely  or  as  far  as  certain  symptoms  are  concerned,  by  the 
simultaneous  administration  of  quinia.  Owing  to  the  energy  with  which  it  paralyzes 
certain  kinds  of  protoplasm,  quinia  diminishes  the  absolute  number  of  white  blood 
corpuscles  in  the  body;  the  lymphatic  glands,  under  its  action,  become  small,  and  are 
found,  on  section,  to  be  abnormally  dry,  while  splenic  enlargements,  due  to  hyperplasia 
of  the  lymphatic  follicles,  and  to  the  increased  tissue  change  within  the  organ  by  which 
it  is  accompanied,  are  reduced  or  prevented. 

The  escape  of  white  blood  corpuscles  from  the  vessels,  and  the  suppuration  which 
ensues,  can  be  distinctly  limited  in  animals  by  quinia  ; its  effect  in  this  instance  is,  in 
the  main,  independent  of  the  condition  of  actual  pressure.  It  is  due  to  a lowering  of 
the  affinity  of  the  corpuscles  for  the  oxygen  of  the  haemoglobin,  this  oxygen  being  the 
stimulus  which  excites  the  independent  movements  by  which  emigration  from  the  veins 
and  capillaries  is  partly  effected.  Fresh  vegetable  juices  containing  protoplasm,  and 
also  healthy  pus— both  of  which  ordinarily  give  the  reaction  of  nascent  oxygen  with 
tincture  of  guaiacum  or  indigo — lose  this  property  when  mixed  with  relatively  weak 
solutions  of  quinia,  this  alkaloid  preventing  the  protoplasm  from  absorbing  oxygen 
from  the  atmosphere  and  undergoing  the  special  alteration  to  which  the  reaction  is  due. 

Phosphorescent  infusoria,  or  those  which  are  continually  undergoing  powerful  oxida- 
tion, completely  lose  their  phosphorescence  on  the  addition  of  minute  quantities  of 
quinia.  The  addition  of  quinia  to  blood  which  has  been  recently  drawn  not  only 
diminishes  the  physiological  production  of  acid  which  occurs  immediately  after  its 
removal  from  the  body,  but  also  its  power  of  transferring  active  oxygen  to  oxidizable 
bodies.  This  effect  also  takes  place  with  pure  li;emoglobiii  without  its  being  possible 
to  detect  any  decomposition  of  the  latter  spectroscopically  during  the  presence  of  the 
quinia.  On  the  contrary,  when  blood  which  contains  quinia  is  heated,  the  lines  which 
indicate  oxygen  disappear  at  a higher  temperature  than  the  same  lines  in  pure  blood 
used  for  comparison.  The  penicillium  fungus,  when  mixed  with  haemoglobin  outside 
the  body,  withdraws  oxygen  from  it,  and  this  process  is  arrested  by  quinia. 

From  the  preceding  facts,  established  by  the  labors  of  eminent  observers,  as  Dr.  C. 
Binz,  Mosler,  Boeck,  Rossbach  and  Preyer,  and  taking  into  consideration  the  altera- 
tions in  size  which  the  red  blood  corpuscles  undergo  under  its  influence,  it  seems  prob- 
able that  while  the  quinia  renders  certain  cells  within  the  human  organism  still  less 
fitted  than  before  for  the  absorption  of  oxygen,  it  binds  that  element  more  firmly  to 
the  haemoglobin.  The  fall  of  temperature  which  quinia  so  frequently  produces  in  fever 
(0.5°,  4.0°,  and  more,  Centigrade)  is  independent  of  the  heart,  and  also  of  those  portions 
of  the  nervous  system  which  take  origin  in  the  brain  and  pass  downward  through  the 
spinal  cord;  for  it  still  takes  place  after  the  cervical  portion  of  the  latter  has  been  com- 
pletely divided  ; nor  does  it  appear  to  depend  upon  an  increased  omission  of  heat  from 
the  skin.  The  reduction  of  temperature  appears  to  be  largely  due  to  some  inhibitory 
effect  exerted  by  quinia  over  the  functional  activity  of  the  protoplasmatic  cells  of  the 
heat-producing  organs.  Even  the  normal  cells  become  slightly  depressed  by  its  action, 
especially  when  they  are  producing  an  unusual  amount  of  heat  under  the  stimulus  of 
pyretic  substances;  and  those  infective  poisons  (whether  they  be  organized  or  merely 
in  solution)  which  are  capable  of  self-multiplication  in  the  body  after  more  or  less  of  a 


518 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


period  of  incubation,  and  of  acting  as  irritants  to  their  cells,  are  either  rendered  by 
quinia  incapable  of  further  development,  as  in  malarial  fever,  or  they  have  their  energy 
paralyzed,  as  happens,  to  some  extent,  in  typhoid  fever.  Quinia  essentially  differs  from 
chemically  allied  molecules — such  as  morphia,  strychnia,  veratria — in  the  fact  that  it 
does  not  meet  with  any  albuminous  body  in  the  nervous  system  on  which  it  has  a 
marked  effect.  Quinia  circulates  unchanged  through  the  blood,  and  it  is  an  error  to 
attribute  its  specific  antipyretic  properties  to  its  stronger  affinity  for  one  or  more  pyretic 
poisons,  and  especially  for  that  form  which  malaria  originates.  The  power  of  quinia  to 
arrest  malarial  fever  is  due  chiefly  (a)  to  its  antipyretic  properties;  ( b ) its  power  to 
bind  the  oxygen  more  firmly  with  the  colored  blood  corpuscles,  and  thus  to  avert  the 
destructive  action  of  the  malarial  germ  or  microorganism;  (c)  its  poisonous  effects  upon 
the  microorganisms  of  malarial  fever;  (d)  its  tonic  effect  upon  the  cerebro-spinal  and 
sympathetic  ganglia. 

PREVENTION  OF  MALARIAL  FEVER. 

No  subject  is  of  greater  importance  to  the  inhabitants  of  tropical  and  temperate 
legions  of  the  earth,  than  the  destruction  or  removal  of  the  cause  or  causes  of  malaria. 

The  following  propositions  should  be  considered  in  the  discussion  of  the  measures 
which  may  be  proposed  for  the  destruction  or  removal  of  the  causes  of  malaria  : — 

1.  Malaria  inflicts  a vast  amount  of  disease  and  suffering  upon  the  human  race,  and 
directly  and  indirectly  causes  a considerable  portion  of  the  mortality  in  tropical  and 
temperate  climates.  Notwithstanding  the  modern  civilizations  had  their  rise  and 
development  in  the  most  malarial  portions  of  Africa,  Asia  and  Europe,  along  the 
banks  of  the  Nile,  in  its  hot,  malarious  delta,  we  find  the  remains  of  an  ancient  and 
grand  civilization,  which  gave  birth  to  that  of  Greece  and  Rome,  and  the  great  commer- 
cial cities  of  the  Phoenicians  were  located  around  the  malarious  borders  of  the  land- 
locked Mediterranean. 

Even  medicine  had  its  first  birth  along  the  marshy  waters  of  the  Nile  and  in  the 
temples  of  Isis  and  Osiris. 

The  works  of  Hippocrates  (the  father  of  European  medicine)  were  based  upon  the 
knowledge  which  had  crossed  the  Mediterranean  from  the  shores  of  Africa,  and  the 
greater  portion  of  the  cases  which  he  details  relate  to  the  various  forms  of  malarial 
fever.  Rome  conquered  the  world  with  the  sword  and  destroyed  her  citizens  by  malarial 
fevers,  and  through  all  her  various  changes,  from  universal  empire  to  a contracted 
hierarchy,  through  all  ages,  she  has  retained  her  deadly  malaria.  In  the  malarious 
regions  of  Italy  and  Spain  were  born  and  reared  Columbus,  Cortez,  Pizzaro,  Ponce  de 
Leon  and  Ferdinand  de  Soto.  In  the  malarious  regions  of  the  Southern  States  were 
bred  such  men  as  Washington,  Jefferson,  Lee  and  Stonewall  Jackson. 

The  star  of  empire,  which  has  been  steadily  passing  from  the  east  to  the  west,  has 
halted  in  its  progress  in  the  great  malarious  valley  of  the  Mississippi,  where  it  will  remain 
as  the  centre  of  political  power,  physical  development  and  scientific  advancement.  In 
those  regions  in  which  the  earth  generates  malaria,  she  also  bestows  her  most  bouu- 
teous  gifts,  golden  grain,  luscious  fruits,  and  every  variety  of  animal  aud  vegetable  food. 
Thus  the  baneful  effects  of  malaria  are  counterbalanced  to  a large  extent  by  the  mild 
and  genial  climate  aud  the  bounteous  products  of  field,  forest,  river,  lake  aud  ocean. 

2.  The  labors  of  man  iu  clearing  the  forests,  opening  and  deepening  the  channels  of 
rivers,  draining  and  tilling  the  land,  have  altered  the  climate  and  changed  the  char- 
acter of  the  diseases  of  large  portions  of  the  earth’s  surface. 

The  malarious  belt  of  the  earth  has  been  thus  progressively  circumscribed  by  the 
labors  of  the  agriculturist.  In  the  present  century  the  removal  of  the  causes  of  mala- 
rial fever  has  been  greatly  facilitated  by  the  extensive  introduction  of  improved  imple- 
ments and  machinery  and  the  use  of  steam.  The  drainage  of  lagoons,  swamps  and 
marshes,  as  well  as  of  the  land  generally,  has  removed  certain  conditions  favorable  to 
the  development  of  simply  constructed  organisms  and  morbific  ferments. 


SECTION  XV — rUBLIC  AND  INTERNATIONAL  HYGIENE.  519 


With  the  increase  of  the  human  race,  and  the  advancement  of  agriculture  and  the 
mechanical  arts,  there  will  be  a progressive  diminution  of  the  empire  of  malaria.  The 
labors  of  the  agriculturist  have  banished  malarious  diseases  from  the  greater  portions 
of  England,  France  and  Germany.  In  the  early  settlements  of  South  Carolina  and 
Georgia  the  clearing  otf  of  the  dense  virgin  forests,  even  in  elevated,  hilly  regions,  was 
attended  with  the  development  of  the  severest  forms  of  remittent  and  congestive 
fevers.  At  this  day  the  old  red  clay  hills  of  Carolina  are  comparatively  free  from 
malarial  fever. 

3.  Centuries  must  elapse  before  the  low  grounds,  marshes,  ponds,  lagoons  and 
swamps  of  the  United  States  of  America,  and  more  especially  of  the  great  valley  of 
the  Mississippi,  will  be  thoroughly  drained  and  under  cultivation.  The  rich  returns 
yielded  by  sugar-cane,  rice  and  cotton  will  ever  tempt  the  laborer  to  disregard  the 
effects  of  climate,  and  the  gaps  in  their  ranks  will  ever  be  speedily  filled  with  new 
recruits.  The  question  arises,  what  can  be  done  to  protect  the  laborers  in  the  swamps, 
rice  fields  and  marshes  of  the  Southern  States  from  the  effects  of  malaria  ? The  author 
has  witnessed,  upon  thousands  of  occasions,  the  destructive  effects  of  malaria  upon  the 
human  constitution. 

If  the  hardy  sons  of  Ireland,  England,  Germany  and  France,  and  even  the  dark 
Latin  races  of  Italy,  Spain  and  Portugal  enter  the  swamps  and  marshes  and  rice-fields 
of  our  Southern  States  as  laborers,  they  are  almost  universally  attacked  with  the  various 
forms  of  malarial  fever  during  the  months  of  July,  August,  September,  October  and 
November.  Many  who  escape  the  immediate  fatal  effects  of  the  acute  form  suffer  with 
diffuse  parenchymatous  hepatitis,  malarial  nephritis,  anaemia,  anasarca,  ascites  and 
prostration  of  the  muscular  and  nervous  forces.  Vast  numbers  of  men  have  perished 
from  the  effects  of  malaria  and  exposure  in  building  the  railroads  of  the  United 
States.  This  subject  should  be  thoroughly  investigated  by  the  National  Government. 
At  the  present  time  vast  numbers  of  men  from  all  parts  of  the  civilized  world  are 
suffering  and  perishing  from  the  deadly  effects  of  the  malaria  of  the  Central  and  South 
American  States,  and  more  especially  from  the  fevers  of  the  Isthmus  of  Panama.  How 
to  protect  the  laborer  from  the  effects  of  malaria  should  call  forth  the  earnest  considera- 
tion of  every  civilized  nation. 

Preceding  the  American  Civil  War,  in  1859  and  1860,  the  author  undertook  an 
extended  investigation  of  the  diseases  of  the  various  geological  and  physical  divisions 
of  the  Southern  (slave  States).  The  investigation  of  the  soil,  waters  and  diseases  of  the 
rice  plantations,  low  grounds  and  swamps  of  Georgia  first  engaged  his  attention.  Upon 
the  present  occasion  we  shall  present  only  two  results  of  these  labors,  namely,  those 
facts  which  illustrate  the  poisonous  nature  of  the  stagnant  water  of  the  swamps  and  the 
rules  formulated  by  the  author  for  removing,  at  least  some  of  the  causes  for  malaria 
from  among  the  laborers  on  the  rice  plantations. 

Poisonous  Effects  of  the  Stagnant  Waters  of  the  Swamps  of  Low  Malarious  Legions. 
Experiments  on  Living  Animals.* — Water  taken  from  a deep  basin  in  the  large  canal 
which  drains  the  rice  fields — the  swamp  was  entirely  dry  with  the  exception  of  the 
deeper  portions  of  the  canal — the  waters  of  which  had  ceased  to  flow  for  at  least  three 
months,  the  season  having  been  unusually  warm  and  dry.  The  fish,  terrapins,  frogs, 
alligators  and  snakes  had  all  collected  in  these  pools  of  stagnant  water,  and  the  living 
catfish  kept  their  mouths  and  feelers  upon  the  surface  of  the  water.  As  the  eye  rested 
upon  the  black  and  green,  turbid  waters,  scarcely  a spot  could  be  discovered  not  occu- 


* “First  Report  to  the  Cotton  Planters’  Convention  of  Georgia,  on  the  Agricultural  Resources 
of  Georgia,”  by  Joseph  Jones,  m.d.,  pp.  269-272.  Augusta,  Ga.,  1860.  Analysis  43.  Stagnant 
swamp  water,  Arcadia  swamp,  Liberty  Co.,  eight  miles  from  its  junction  with  the  North  New  Port 
River,  June  1st,  1860. 


520 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


pied  by  the  mouths  and  feelers  of  catfish  moving  tremulously  about  upon  the  surface 
of  the  water  like  so  many  spiders  ; in  fact,  upon  a general  view,  these  pools  resembled 
a dark  surface  of  black  and  green  liquid  mud,  upon  which  thousands  of  large  spiders 
were  dancing.  Every  now  and  then  the  monotony  would  he  broken  by  the  splash  of  a 
mudfish  or  garfish,  or  conger  eel,  or  the  plunge  of  a hull-frog.  The  catfish  appeared,  in 
their  distress  and  anxiety  to  absorb  the  oxygen  from  the  atmosphere,  to  disregard  alike 
the  presence  of  man  and  of  the  moccasins  and  water  snakes  which  sluggishly  moved  in 
the  stagnant  pools  among  their  feelers,  apparently  satiated  and  disgusted.  These  stag- 
nant pools,  and  in  fact  the  whole  swamp,  under  a burning  sun  emitted  a most  sickening 
and  disgusting  stench.  Exposure  to  this  atmosphere,  contaminated  with  the  gases 
arising  from  the  decomposition  of  vegetable  and  animal  matter,  during  the  heat  of  the 
day,  from  ten  o’clock  in  the  morning  until  three  o’clock  in  the  afternoon,  obtaining 
specimens  of  water  and  capturing  the  cold-blooded  reptiles,  was  followed  before  night 
by  an  active  diarrhoea.  I have  before  suffered  in  a similar  manner  from  exposure  to 
these  swamps  in  the  summer  season.  Sulphate  of  quinia  taken  upon  the  appearance  of 
the  first  symptoms  of  lassitude  and  of  undue  action  of  the  bowels  was  the  means  of 
relieving  the  unpleasant  effects  of  this  exposure  in  two  days  ; and  I have  upon  other 
occasions,  when  I have  been  similarly  exposed  in  the  prosecution  of  my  inquiries,  expe- 
rienced beneficial  effects  from  sulphate  of  quinia  used  as  a prophylactic. 

The  power  which  quinia  possesses  of  averting  an  attack  of  malarial  fever  is  most 
valuable  to  the  planters  of  these  regions,  who  are  often,  during  the  harvesting  of  rice, 
necessarily  exposed  to  the  deleterious  effluvia  of  the  swamps.  That  the  diarrhoea  was 
caused  by  the  effluvia  of  these  swamps,  inhaled  during  the  collection  of  the  waters  and 
samples  of  the  swamp  mud  and  of  the  natural  history  specimens,  was  proved  by  the 
fact  that  my  servant  man  (a  strong,  healthy  negro,  who  resided  on  the  plantation  one 
mile  from  this  swamp),  who  assisted  in  procuring  the  specimens,  was  also  attacked  at 
night  with  diarrhoea.  I was  anxious  to  test  the  effects  of  these  waters  when  absorbed 
directly  into  the  blood.  They  were  placed  in  bottles  hermetically  sealed,  and  upon  my 
return  to  Augusta,  two  days  after,  I injected  several  fluid  ounces  into  the  subcutaneous 
tissue  of  a large  Newfoundland  dog.  The  water  was  injected  into  the  subcutaneous 
tissue  of  the  back  and  right  fore  and  hind  legs.  At  the  time  of  the  injection  the  water 
had  the  same  sickening  smell  of  the  swamp.  No  special  symptoms  were  induced  by 
the  injection  of  the  water  at  the  time,  but  upon  the  next  day  there  was  a slight  rise  in 
the  temperature  of  the  dog,  and  the  parts  upon  the  back  and  legs  where  the  swamp 
water  had  been  injected  were  greatly  swollen.  Upon  the  third  day  the  parts  were 
lanced  and  discharged  much  green  and  yellowish-green,  exceedingly  offensive  matter, 
together  with  much  most  foul  and  fetid  air.  The  parts  continued  to  discharge  large 
quantities  of  foul  matter  and  air  for  ten  days.  Tar  was  applied  liberally  around  and 
within  the  orifices  of  the  abscesses,  to  keep  away  the  flies,  which  I am  confident  would  have 
destroyed  the  dog.  The  dog  lost  flesh  to  a considerable  degree,  but  recovered  entirely 
in  three  weeks.  At  the  end  of  one  month  he  was  killed  by  the  subcutaneous  injection 
of  acetate  of  morphia,  and  a careful  examination  with  the  naked  eye  aud  with  the 
microscope  was  made  of  all  the  viscera  ; no  lesions  of  the  organs  were  discovered,  and 
no  alterations  of  the  viscera  were  manifest,  the  color  of  the  liver  was  natural,  aud  the 
spleen  was  not  enlarged.  The  swamp  water  was  not  injected  directly  into  the  blood- 
vessel system,  for  I felt  confident  that  the  animalcules  and  suspended  matters  which 
could  not  be  removed  by  filtration  would  have  produced  death  by  interfering  with  the 
capillary  circulation  in  the  lungs,  independently  entirely  of  any  direct  poisonous  effects. 
The  highly  complex  nature  of  these  waters  will  be  seeu  in  the  following  analysis : 
Specific  gravity,  1000.661  ; solid  residue  in  100,000  grains,  23.400;  suspended  matters 
in  100,000  grains,  100.000  ; 100,000  grains  contain  suspended  matters,  100  grains ; phos- 
phates of  lime  and  magnesia,  22.224  ; phosphoric  acid,  13.958  ; lime  and  magnesia, 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  521 


8.266  ; chlorides  of  sodium,  potassium,  calcium  and  magnesium,  sulphates  of  soda, 
potassa,  lime  aud  magnesia,  phosphates  of  soda  and  potassa,  5.733  ; organic  matters, 
animalcules,  microscopic  plants,  decaying  animal  and  vegetable  matters,  urea,  uric 
acid,  salts  of  ammonia,  creuic,  apocrenic  and  humic  acids,  15.101  ; silicates  of  alumina, 
potassa  and  lime,  silicic  acid,  peroxide  of  iron,  56.892.  Gases. — Sulphureted  hydrogen, 
3.488  ; sulphur,  3.283  ; hydrogen,  205  ; phosphoreted  hydrogen,  carbureted  hydrogen, 
carbonic  acid  gas,  carbonic  oxide  gas,  atmospheric  air,  oxygen,  nitrogen,  and  other  gases. 
Solid  residue,  23.400;  carbonate  of  lime,  3.122;  lime,  1.487;  carbonic  acid,  1.635; 
carbonate  of  magnesia,  0.455  ; magnesia,  0.217  ; carbonic  acid,  0.238  ; chlorides  sodium 
and  potassium,  2.946  ; sodium  and  potassium,  1.350  ; chlorine,  1.596  ; sulphates  soda 
and  potassa,  4.223  ; soda  and  potassa,  2,050  ; sulphuric  acid,  2.173  ; silicic  acid,  0.213  ; 
phosphates  of  soda,  potassa,  lime  and  magnesia,  trace  ; chlorides  of  magnesium,  calcium 
and  aluminum,  trace  ; organic  matters,  humic,  ulmic,  creuic  and  apocrenic  acids,  ani- 
malcules, microscopic  plants,  ammonia,  urea,  uric  acid,  urate  of  ammonia,  2.450 ; 
putrefying  vegetable  and  animal  matters,  undefined  vegetable  and  animal  matters. 

We  thus  demonstrated  in  1860  the  poisonous  nature  of  the  waters  of  swamps  and  their 
power  to  produce  fever  and  dysentery  in  living  animals  when  injected  subcutaneously. 

During  the  treatment  of  6311  cases  of  disease  in  the  wards  of  the  Charity  Hospital 
of  New  Orleans,  1869-1886,  nearly  one-half  of  which  were  caused  by  the  action  of 
malaria,  I have  sought  to  investigate  the  proximate  cause  of  the  first  and  subsequent 
attacks.  A large  number  of  the  cases  of  malarial  fever  and  of  acute  and  chronic  dys- 
entery and  diarrhoea  can  be  traced  to  the  drinking  of  swamp  water  and  the  waters  of 
sluggish  bayous  and  streams,  and  of  wells  sunk  in  low  malarious  regions. 

In  the  month  of  October,  1880,  during  a personal  inspection  of  the  cases  of  Oriental 
leprosy  along  the  banks  of  the  Bayou  Lafourche,  I was  accompanied  by  my  son,  Stan- 
hope Jones,  at  that  time  a cadet  of  the  State  University  of  Baton  Rouge  (now  doctor 
and  assistant  coroner).  The  water  of  the  Bayou  Lafourche  (all  that  could  be  obtained 
for  drinking  purposes)  produced  a succession  of  violent  hemorrhages  from  the  bowels  of 
my  son,  and  had  I not  reached  Lockport  at  midnight  and  secured  the  kind  assistance 

Iof  physicians  and  friends  and  the  necessary  remedies,  death  would  have  been  inevit- 
able. A large  number  of  ulcers  of  the  lower  extremities  treated  in  my  wards  in  the 
Charity  Hospital  have  been  traced  to  the  action  of  the  poisonous  waters  of  the  swamps 
and  rice  fields  of  Louisiana;  and  at  the  present  time,  November,  1886,  I have  under 
treatment  a case  of  extensive  ulceration  of  both  lower  extremities,  complicated  with 
anaemia,  jaundice,  enlarged  liver,  enlarged  spleen  aud  fever,  occurring  in  the  case  of  a 
man  who  had  been  cutting  cypress  logs  in  the  swamps  near  Plaquemine,  Louisiana.  In 
dealing  with  such  ulcers,  the  local  treatment  will  not  avail  unless  the  constitutional 
treatment  at  the  same  time  be  carried  on  against  the  malarial  fever  and  its  effects. 
During  my  labors  among  the  rice  and  cotton  plantations  of  Georgia,  in  1860,  I was  led 
to  draw  up  the  following  rules  with  reference  to  the  use  of  the  waters  and  the  general 
conduct  of  the  laborers. 

Waters  of  the  Wells  and  Springs  of  the  First  Tertiary  Plain* — The  character  of  the 
waters  of  the  springs  and  wells  of  the  low  lands  bordering  the  sea,  of  Georgia,  will 
depend  upon  the  depth  and  character  of  the  soil  and  their  distance  from  the  rivers  and 
swamps.  The  springs  and  wells  of  water  in  sandy  formations  are  of  great  purity,  and 
their  composition  is  correctly  represented  in  analysis  forty-one  of  IValthourville  branch 
waters.  In  many  of  these  springs  and  wells  which  are  formed  by  the  waters  perco- 
lating through  sand  beds,  which  serve  the  purpose  of  natural  filters,  the  saline  matters 
are  often  not  more  than  from  one  to  three  grains  in  the  gallon.  The  waters  of  low, 


* “First  Report  to  tlio  Cotton  Planters’  Convention  of  Georgia,’’  etc.,  by  Joseph  Jones,  m.d., 
Augusta,  Georgia,  1860,  pp.  285-289. 


522 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


swampy  lands  and  rice  fields,  on  the  other  hand,  are  impregnated  with  organic  matters 
which,  in  certain  seasons  and  under  certain  conditions,  exert  most  deleterious  effects 
upon  the  health  of  the  inhabitants.  The  great  mortality  upon  rice  places,  many  of 
which  actually  decrease  instead  of  increasing,  is  due  to  the  character  of  the  waters, 
which  induce  bowel  affections  and  derangement  of  the  blood  and  low  grades  of  fever. 
The  relations  of  malarial  fever  to  the  organic  matters  of  drinking  waters  demand  a 
most  searching  and  extensive  investigation,  and  without  hazarding  an  opinion  at  this 
stage  of  the  investigation,  we  would  simply  state  that  we  have  been  engaged  in  an 
examination  of  this  complicated  question  as  well  as  of  the  character  and  causes  of  these 
diseases  of  rice  plantations,  and  hope  to  present  a special  report  at  some  future  day. 
Upon  the  present  occasion  I will  point  out  a few  practical  rules  which  I know,  by  expe- 
rience, will  greatly  ameliorate  the  condition  of  the  inhabitants  of  rice  plantations: — 

1.  Substitute  cistern  water  for  well  and  spring  water.  If  this  report  should  accom- 
plish no  other  result  than  the  introduction  of  cisterns  upon  rice  plantations  and  in  the 
tertiary  lime  formation  of  Georgia,  I shall  feel  myself  to  be  rewarded  for  my  labors. 
The  surface  exposed  by  the  cotton  gins,  sheds  and  barns  and  dwelling  houses  upon 
plantations  will  prove  amply  sufficient  for  the  collection  of  an  abundant  supply  of 
water. 

2.  If  the  cistern  water  should  at  any  time  fail,  or  if  it  be  impossible  to  obtain  the  cis- 
tern water,  then  collect  the  well  and  spring  water  into  large  barrels  or  tanks,  and  add 
to  the  mass  of  water  a solution  of  common  alum.  One  pound  of  alum  pulverized  and 
dissolved  in  four  gallons  of  water  will  be  sufficient  to  purify  the  drinking  water  of  a 
large  plantation  for  six  months.  Of  this  solution  a wineglassful  may  be  added  to 
every  fifty  gallons  of  water.  The  alum  coagulates  the  organic  matters,  they  settle  and 
leave  a clear,  sparkling,  wholesome  water.  The  minute  proportion  of  alum  in  the 
water  will  exert  no  injurious  effects  whatever  ; it  will  be  only  tonic  in  its  action. 

3.  Never  commence  work  in  the  fields  and  low  grounds  before  sunrise. 

4.  Never  allow  the  laborers  to  commence  work  upon  empty  stomachs.  Establish  a 
law,  as  unalterable  as  those  of  the  Medes  and  Persians,  that  no  one  shall  leave  the 
quarters  without  having  first  cooked  and  eaten  breakfast.  Breathing  in  the  morning  in 
an  atmosphere  loaded  with  the  noxious  vapors  of  the  swamps  is  the  most  fruitful  of 
all  sources  of  disease. 

5.  Avoid,  as  far  as  possible,  the  dews  of  the  mornings  and  nights. 

6.  Avoid  wet  clothes,  as  far  as  possible. 

7.  Clothe  the  feeble,  during  the  fall  and  winter,  in  red  flannel,  worn  next  to  the 
akin. 

8.  Treat  diseases  of  rice  plantations  and  low  grounds  upon  the  stimulant  plan. 
Avoid  all  depletion  as  far  as  possible,  and  in  the  climate  fevers  administer  sulphate  of 
quiuia  boldly,  regardless  of  the  symptoms  of  headache  and  delirium;  for  this  is  the 
great  remedy  in  the  diseases  of  swamps  and  rice  fields,  even  in  the  pleurisy  and  pneu- 
monia of  the  winter  season,  for  they  are,  in  this  section  of  the  country,  modified  by  the 
slow  action  of  malaria  upon  the  system. 

9.  Do  not  attribute  the  diseases  of  children  in  the  summer  and  fall  to  worms.  At 
this  period  of  the  year,  when  children  are  most  liable  to  climate  fever,  it  is  the  habit 
of  so  many  planters  to  dose  them  with  various  drastic  and  disgusting  mixtures,  to  rid 
them  of  worms,  under  the  idea  that  the  worms  are  the  cause  of  the  fevers  of  this  season 
of  the  year,  because,  when  the  children  are  taken  sick,  the  worms  travel  away  from 
them  through  every  avenue  and  in  every  direction.  The  explanation  of  this  striking 
phenomenon,  which,  upon  a superficial  view,  is  liable  to  be  taken  for  the  disease,  is 
simply  this:  during  the  attack  of  climate  fever  the  secretious  of  the  liver,  and  of  the 
whole  intestinal  canal,  are  so  altered  that  the  worms,  which  have  been  quietly  housed 
all  winter  in  comfortable  quarters,  without  exciting  any  injurious  effects  upon  the 


SECTION  XV — --PUBLIC  AND  INTERNATIONAL  HYGIENE.  523 

unconscious  landlords,  are  suddenly  sickened  and  disgusted  with  their  altered  fare 
and  habitations,  and  beat  a precipitate  retreat  in  the  most  convenient  and  natural 
directions. 

If  you  treat  the  disease  for  worms  alone,  the  real  disease,  climate  fever,  will  march 
steadily  on,  and  you  may  purge  the  child  until  the  last  worm  is  evacuated,  and  only 
hasten  the  fatal  end,  because  you  are  working  in  conjunction  with  the  disease,  all  the 
tendencies  of  which  are  depressing.  If,  on  the  other  hand,  you  administer  a gentle 
purgative  mixed  with  a full  dose  of  sulphate  of  quinia,  and  follow  up  with  gentle 
stimulants  and  sulphate  of  quinia,  the  termination  of  almost  every  case  will  be  favor- 
able, and  that,  too,  in  a few  days.  We  are  persuaded  that  strict  attention  to  these 
simple  rules  will  be  the  means  of  materially  diminishing  the  diseases  and  the  rate  of 
mortality  upon  rice  plantations. 

Quinine  as  a Preventive  of  Malarial  Fever* — The  following  observations  have  lost 
none  of  their  interest  or  value  by  the  course  of  events;  in  fact,  such  inquiries  are  ren- 
dered more  valuable  than  ever  by  the  changes  wrought  by  the  war  in  the  labor  system 
of  the  South.  The  Southern  States  must  do  all  in  their  power  to  promote  and  foster 
white  immigration,  and  all  facts  are  of  interest  which  bear  upon  the  health  of  white 
laborers  in  the  cultivation  of  the  rich  swamps  and  rice  lands,  which  in  many  places 
are  now  lying  idle  and  rapidly  reverting  back  to  their  original  state.  At  the  commence- 
ment of  the  recent  war  I prepared  and  published  an  article  in  the  Southern  Medical  and 
Surgical  Journal,  entitled  “Sulphate  of  Quinia  administered  in  small  doses  during 
health,  the  best  means  of  preventing  Chills  and  Fever,  and  Bilious  Fever,  and  Congestive 
Fever,  in  those  exposed  to  the  unhealthy  climate  of  the  rich  low  lands  and  swamps  of 
the  Southern  Confederacy.”  Owing  to  the  state  of  the  country  at  the  time,  this  publi- 
cation was  not  circulated  in  the  manner  designed.  The  climate  of  the  rich,  low  plain, 
clothed  with  a luxuriant,  sub-tropical  vegetation,  which  forms  a belt  along  the  Atlantic 
Ocean  and  Gulf  of  Mexico  of  varying  width,  from  thirty  to  a hundred  miles,  and  which 
is  intersected  with  numerous  swamps,  which  discharge  their  waters  into  sluggish,  muddy 
streams,  surrounded  on  all  sides  by  extensive  swamps  and  marshes,  is,  necessarily,  hos- 
tile to  the  white  race.  To  the  pestilential  exhalations  of  stagnant  swamps  and  rich 
river  deposits,  excited  and  disseminated  by  the  burning  rays  of  the  sun  in  this  hot 
climate  during  the  summer  and  fall  months,  no  process  of  acclimation  has  ever  accus- 
tomed the  white  man.  In  the  early  settlement  of  South  Carolina  and  Georgia,  the 
inhabitants,  in  most  instances,  resided  the  whole  year  upon  their  rich  rice  and  indigo 
plantations.  Many,  however,  soon  fell  victims  to  the  climate  or  dragged  out  a miserable 
existence,  with  constitutions  broken  and  rendered  prematurely  old  by  repeated  attacks 
of  climate  fever.  The  clearing  of  the  forests,  of  the  swamps  and  rich  low  lands,  and 
the  consequent  exposure  to  the  sun  of  the  vegetable  matter  which  had  been  accumulat- 
ing for  ages,  rendered  the  climate  so  deleterious  to  the  white  race  that  the  planters  were 
compelled  to  seek  health  during  the  summer  and  fall  months  iu  sea  islands,  or  in  pine 
barren  or  mountainous  retreats;  and  with  the  most  efficient  precautions  the  mortality 
of  these  regions  is  far  greater  than  in  the  elevated  portions  of  the  Southern  States. 

The  preceding  statement  has  been  fully  illustrated  in  the  fourth  chapter  of  the 
present  (second)  volume  of  the  “Medical  and  Surgical  Memoirs,”  by  reference  to  the 
mortuary  records  of  Midway  Congregational  Church,  of  Liberty  County,  Georgia,  and 
by  the  experience  of  the  British  officers  in  Africa. 

The  facts  which  have  now  been  fully  presented  are  sufficient  to  justify  the  attempt 
to  devise  some  means  to  ward  off  the  climate  fever.  During  the  study  of  the  relations  of 


*“  Quinine  as  a Prophylactic  against  Malarial  Fever,”  being  an  appendix  to  the  “Third 
Report  on  Typhoid  and  Malarial  Fevers,”  delivered  to  the  Surgeon-general  of  tho  late  C.  S.  A., 
August,  1864.  By  Joseph  Jones,  m.d. 


524 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


climate  and  soil  to  disease,  the  collection  of  the  mortuary  statistics  and  the  investigation 
of  the  causes  of  diseases  upon  rice  and  cotton  plantations,  and  during  the  discharge  of 
the  duties  of  chemist  to  the  Cotton  Planters’  Convention  of  Georgia,  the  author  has, 
necessarily,  been  greatly  exposed  to  the  agents  which  produce  climate  fever,  and  the 
results  of  his  experience,  now  presented,  cannot,  therefore,  be  said  to  be  wanting  the 
test  of  actual  experiment.  Under  these  exposures,  I have  found  the  sulphate  of  quinia, 
taken  in  from  three  to  five  grains  twice  during  the  day,  would,  in  most  cases,  prevent 
the  occurrence  of  malarial  fever,  and  if  it  failed  to  ward  it  off  entirely,  the  attack 
would  be  of  a very  slight  character.  I have  further  observed  that  when  the  climate 
fever  first  appeared— with  a sense  of  lassitude,  headache  and  excitement  of  the  puLse, 
with  alternate  flushings,  it  might  be  arrested  by  a dose  of  from  five  to  ten  grains  of 
sulphate  of  quinia,  in  combination  with  bicarbonate  of  potassa  and  Hoffman’s  anodyne. 
From  five  to  ten  grains  of  the  sulphate  of  quinia  may  be  given,  according  to  the  urgency 
of  the  symptoms,  united  with  fifteen  grains  of  bicarbonate  of  potassa  aud  two  fluid 
drachms  of  Hoffman’s  anodyne,  from  five  to  fifteen  grains  of  gum  camphor;  the  whole 
to  be  dissolved  in  six  fluid  drachms  of  water.  The  feet  should  be  placed  in  hot  water 
immediately  after  or  before  the  administration  of  the  remedies,  and  the  patient,  after 
this  bath,  should  be  covered  up  in  bed,  so  as  to  promote  free  perspiration  and  induce 
quiet  sleep.  I have  frequently  gone  to  bed  in  a feverish,  restless  state,  with  a severe 
headache,  excited  pulse,  aud  pain  in  the  limbs,  and  dry,  warm  skin,  and,  under  the 
action  of  these  remedies,  arose  in  the  morning  refreshed  and  able  to  resume  active 
operations.  The  bicarbonate  of  potash  is  here  recommended  instead  of  the  proto-car- 
bonate (salts  of  tartar),  which  is  in  such  common  use  during  fever  in  the  Southern 
couutry,  because  it  is  far  less  active  in  its  effects  upon  the  stomach,  and  may  be  taken 
in  much  larger  doses,  and  accomplishes  more  effectually  the  neutralization  of  the  acid 
which  is  so  often  abundant  in  the  stomach  at  the  commencement  of  malarial  fever,  and 
more  effectually  acts  upon  the  liver  and  kidneys,  'and  promotes  the  removal  of  all 
offending  matters  from  the  blood. 

We  would  recommend  the  use  of  quinia  as  a preventive  of  climate  fever  in  the 
following  manner: — 


1&  Sulphate  of  quinia gr.  iij 

Dilute  aromatic  sulphuric  acid drops,  v 

Brandy tablespoonful,  j 

Water wineglassful,  ij. 


Drop  the  diluted  aromatic  sulphuric  acid  upon  the  sulphate  of  quinia,  and  then  add 
the  brandy  and  water.  Administer  twice  during  the  day,  after  rising  in  the  morn- 
ing and  just  before  bedtime. 

To  render  the  value  of  this  means  of  warding  off  climate  fever  still  more  evident, 
We  have  cited  in  the  fourth  chapter  the  practice  and  success  of  the  British  surgeons 
upon  the  coast  of  Africa,  premising  at  the  outset,  that  the  epidemic  climate  fever  of 
Africa  does  not  differ  in  any  essential  manner,  except,  perhaps  in  its  severity,  either  in 
its  causes,  symptoms  or  effects,  from  the  malarial  fever  of  North  America.  The  value 
of  sulphate  of  quinia  in  warding  off  the  climate  fever  of  Africa,  has  been  determined 
by  instituting  a comparison  between  the  effects  of  the  disease  before  and  after  the  use 
of  this  medicine  as  a prophylactic.  It  is  worthy  of  notice  that  in  the  instances  in 
which  the  author  has  quoted  from  the  experience  of  the  British  surgeons  serving  in 
Africa,  when  quinine  wine  was  administered  according  to  the  instructions  issued  with 
it,  no  fever  of  any  consequence  followed  exposure  to  land  or  swamp  miasma  ; but,  on 
two  occasions,  when  quinine  purchased  on  the  coast  was  substituted,  and  once  when 
the  wine  was  suddenly  discontinued  after  the  exposure,  a considerable  number  ot 
men  were  attacked,  owing,  it  is  to  be  supposed,  to  the  discontinuance  of  the  quinine 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  525 

wine  in  one  instance,  and  to  its  had  quality  in  the  other,  for  it  is  well  known  that,  like 
other  high-priced  remedies,  it  does  not  escape  adulteration  when  it  falls  into  the  hands 
of  dishonest  traders.* 

A comparison  of  these  facts  with  the  great  sickness  and  mortality  of  the  white 
explorers  and  residents  and  sailors  of  the  African  coast  and  rivers,  demonstrates 
conclusively  : — 

1.  Quinine  taken  during  exposure  to  the  exhalations  of  miasmatic  regions  will,  in 
most  cases,  ward  off  fever  entirely. 

2.  If  fever  attacks  those  to  whom  the  quinine  has  been  regularly  administered,  its 
severity  and  duration  will  be  far  less  than  in  those  who  have  not  taken  the  quinine;  it 
therefore  not  merely  wards  off  disease,  but  renders  it  less  powerful  and  destructive 
when  present. 

3.  To  he  entirely  efficient  the  quinine  must  he  administered  for  some  time,  at  least 
ten  days,  after  exposure  to  the  causes  of  fever.  Southern  Medical  and  Surgical  Journal , 
Augusta,  Georgia,  August,  1861,  Vol.  xvii,  No.  8,  pp.  593-614. 

The  observations  which  I have  been  able  to  make  during  the  late  war  have  con- 
firmed the  accuracy  of  the  preceding  statement ; and  I am  convinced  that  the  health 
and  efficiency  of  the  troops  in  certain  malarious  localities  of  the  Confederacy  would 
have  been  greatly  promoted  by  the  daily  use  of  quinine  in  the  manner  recommended. 
The  value  of  quinine  as  a prophylactic  in  preserving  the  efficiency  of  troops  serving  in 
damp,  unhealthy,  malarious  regions  may  be  readily  demonstrated  by  a direct  calcula- 
tion. The  following  table  illustrating  the  numerical  relations  of  malarial  fever  to  the 
other  diseases,  and  its  effect  in  reducing  the  strength  of  the  command  serving  at  Fort 
Jackson  and  the  surrounding  river  batteries,  situated  in  the  low  rice  lands  of  the 
Savannah  river,  will  furnish  sufficient  data  for  the  calculation: — 


TABLE. 

CASES  OF  MALARIAL  FEVER  AND  ALL  DISEASES  OCCURING  DURING  A PERIOD  OF 
FIFTEEN  MONTHS,  OCTOBER,  1862,  TO  JANUARY,  1864,  IN  THE  COM- 
MAND SERVING  IN  AND  AROUND  FORT  JACKSON,  ON  THE 
SAVANNAH  RIVER. 


Month  and  Year. 

Congestive  Fever. 

Intermittent  Fever, 
Quotidian. 

Intermittent  Fever, 
TertiaD. 

Intermittent  Fever 
Quartan. 

Remittent. 

Total  Cases  of  those 
Forms  of 
Malarial  Fever. 

Total  Cases  for  all 
other  Diseases. 

Total  Cases  of  all 
other  Diseases. 

Aggregate  sick 
each  month. 

Mean  Strength  of 
Command, 
Officers  and  Men 

October,  1862 

262 

71 

12 

345 

126 

471 

583 

872 

November,  1862 

67 

24 

5 

96 

44 

140 

218 

913 

December,  1862 

128 

58 

11 

197 

118 

315 

350 

913 

January,  1863 

42 

88 

5 

135 

172 

307 

331 

1144 

February, 1863 

85 

104 

9 

198 

149 

347 

428 

913 

Marco,  1863 

78 

133 

33 

2 

246 

143 

389 

458 

913 

April,  1863 

37 

157 

4 

198 

226 

424 

489 

913 

May,  1863 

62 

76 

2 

140 

184 

324 

360 

878 

June,  1863 

66 

60 

10 

142 

131 

273 

316 

878 

July,  1863 

77 

177 

67 

321 

137 

458 

504 

878 

August.  1863 

99 

149 

134 

380 

103 

483 

533 

890 

September,  1863 

119 

127 

134 

410 

98 

508 

588 

822 

October,  1863 

97 

108 

62 

267 

133 

400 

485 

660 

November,  1863 

1 

47 

54 

22 

124 

60 

181 

235 

789 

December,  1863 

1 

41 

62 

10 

114 

111 

225 

279 

800 

Total 

2 

1337 

1454 

33 

489 

3313 

1935 

5248 

* “ Statistical  Report  of  tho  IIoaRh  of  the  Royal  Navy,  for  tho  year  1857,”  ordered  by  the 
House  of  Commons  to  be  printed,  August  21,  1859,  pp.  78-85. 


52G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  an  average  command  of  878  men,  stationed  at  Fort  Jackson  and  the  surrounding 
river  batteries,  nearly  one-half,  or  410,  on  an  average,  were  on  the  sick  list  each  month; 
and  the  new  cases  of  malarial  fever  averaged  each  month  220.  During  this  period  of 
fifteen  months  3313  cases  of  malarial  fever,  in  the  form  of  congestive  fevers,  quotidians, 
tertians,  quartans  and  remittents,  occurred,  while  all  other  diseases,  including  also  those 
diseases,  as  neuralgia,  which  might  be  traced  in  a measure  to  the  action  of  malaria, 
numbered  1935  cases,  or  only  a little  more,  than  one-half  the  number  of  the  cases  of 
malarial  fever. 

Throughout  the  entire  period  more  than  one-fourth  of  the  command  were  unfit  for 
duty;  and  during  the  fall  months  more  than  one-half  of  the  garrison  was,  on  an 
average,  incapable  of  performing  military  duty.  In  case  of  an  attack  during  the  sick- 
liest season  of  the  year  the  effective  force  of  the  command,  instead  of  being  878,  would 
be  less  than  500.  In  using  quinine  as  a prophylactic  in  such  a command  it  would  be 
necessary  to  administer  the  drug  at  least  five  months,  namely,  June,  July,  August, 
September  and  October.  If  three  grains  of  quinine  in  a gill  of  whisky  be  adminis- 
tered daily  to  each  soldier  we  may  safely  estimate  the  amount  of  quinine  necessary  to 
protect  each  man  during  these  five  months  at  about  one  ounce.  This  command  of  878 
men  would,  therefore,  require  for  its  protection  annually  about  878  ounces  of  sulphate 
of  quinia. 

During  a period  of  twelve  months,  from  October,  1862,  to  November,  1863,  2808 
cases  of  malarial  fever  were  treated,  and  if  we  allow  fifty  grains  of  quinine  as  necessary 
on  an  average  to  the  treatment  of  each  case,  very  nearly  300  ouuces  of  quinine  would 
be  consumed  in  the  treatment  of  these  cases.  It  is  important  also  to  bear  in  mind  that 
this  amount  of  quinine  would  in  many  cases  produce  only  temporary  relief,  after  the 
disease  was  once  established,  and  would  be  powerless  when  thus  occasionally  used  to 
prevent  the  serious  lesions  of  the  spleen  and  liver,  and  the  disease  would  be  liable  to 
return  again  upon  the  slightest  exposure  to  the  original  cause,  or  to  cold  and  damp, 
even  in  healthy  regions.  It  should  be  further  considered  that  the  process  of  acclimation 
in  the  white  race  is  slow,  if  not  altogether  impossible  in  our  Southern  swamps  and  rice 
fields,  and  that  an  entire  command  might  be  gradually  rendered  unfit  for  service  by 
the  effects  of  malaria  in  such  a locality  as  Fort  Jackson;  and  even  after  the  men  are 
removed  to  healthy  regions  they  are  liable  for  many  months,  and  even  for  years,  to  a 
recurrence  of  the  various  forms  of  malarial  fever. 


Amount  of  quinine  necessary  to  protect  878  men  from  malarious  diseases,  during 

twelve  months,  887  ounces  at  an  average  cost  of  $5.00  per  ounce $4390  00 

Amount  of  quinine  necessary  to  treat  2S08  cases  occurring  among  a command  of  S78 

men,  during  twelve  months,  at  an  average  cost  of  $5.00  per  ounce 1500  00 


Difference  of  cost  of  quinine  in  protecting  and  treating  these  cases $2S90  00 


According  to  this  calculation  the  quinine  necessary  to  protect  the  soldier  from  mala* 
rial  fever  would  cost  $2890  more  tliau  that  assumed  to  be  necessary  to  treat  the  cases 
of  fever  arising  where  no  quinine  had  been  used  as  a prophylactic.  We  must,  however, 
introduce  into  this  calculation  the  pay  of  the  sick,  officers  and  men,  which  may  justly 
be  considered  as  an  unproductive  expenditure.  If  we  place  the  number  of  men  con- 
stantly on  the  sick  list  and  unfit  for  duty  from  malarial  fever  at  100,  which  is  far  below 
the  actual  number,  and  if  we  rate  them  as  privates  alone,  each  month  $1100  would  be 
expended  in  the  payment  of  sick  men,  or  $13,200  would  be  annually  expended  without 
any  return  whatever  to  the  Confederacy.  If  we  add  to  this  the  pay  of  sick  officers  the 
sum  would  reach  a much  higher  figure ; but  we  simply  desire  to  demonstrate  the 
utility  of  the  use  of  quinine  as  a prophylactic,  beyond  all  cavil,  even  as  a mere  mat- 
ter of  dollars  and  cents. 


I 


SECTION  XV — rUBLIC  AND  INTERNATIONAL  HYGIENE.  527 

Unproductive  pay  of  100  men  for  twelve  months,  laboring  under  the  various  forms  of 

malarial  fever  (SI 0 per  month  for  each  man) $13,200 

Increased  cost  of  quinine  for  the  protection  of  the  entire  command  during  twelvo  months  2,890 

Difference  in  favor  of  the  use  of  quinine  as  a prophylactic $10,310 


It  should  also  be  taken  into  the  account  that  the  expenses  in  food,  nursing,  hospital 
accommodations,  other  necessary  medicines  and  transportation  for  the  sick,  are  greater 
than  the  expenses  of  the  supplies  of  the  well  soldiers;  and  it  would  be  just,  even  to 
consider  that  the  expenditures  for  the  sick  are  a total  loss,  for  they  certainly  add 
nothing  to  the  defence  of  the  country  or  the  efficiency  of  the  army.  But,  leaving  this 
entirely  out  of  the  calculation,  we  have  demonstrated  clearly  that  the  use  of  quinine 
as  a prophylactic  would  be  attended  with  an  actual  saving  of  expense,  for  in  exposed 
malarious  localities  a less  number  of  troops,  properly  protected,  could  be  made  to  per- 

Jforru  more  efficiently  the  duties  of  a much  larger  force.  Surely  the  accomplishment  of 
such  a result  is  of  value  in  a contest  in  which  we  are  opposed  to  a powerful  enemy,  who 
outnumbers  us  in  the  ratio  of  three  to  one,  and  who,  with  almost  exhaustless  resources, 
has  his  ports  opeu  to  the  commerce  of  the  world.  The  argument  which  might  be  urged 
on  the  score  of  humanity  is  even  stronger  than  that  based  upon  efficiency  and  economy. 
We  must  believe  that  the  preservation  of  our  soldiers  from  acute  diseases,  as  well  as 
from  chronic  affections,  with  enlarged  spleens,  impoverished  and  watery  blood,  dropsies 
and  innumerable  nervous  derangements,  excites  some  interest  and  concern  in  the  minds 
of  their  officers,  as  well  as  their  relatives  and  friends  at  home.  The  difficulties  of 
importing  quinine  at  the  present  time  are  without  doubt  numerous,  but  they  are  not 
greater,  and  are  perhaps  far  less,  than  the  difficulties  of  the  importation  of  the  more 

I bulky  articles  of  clothing  and  luxury,  which  has  been  carried  on  to  such  an  extent  as 
to  drain  the  country  of  gold,  and  to  seriously  endanger  the  moral  and  financial  condi- 
tion of  the  Confederacy.  With  the  large  amount  of  cotton  at  the  command  of  the 

I people  and  the  government,  it  would  not  be  an  impossibility  to  import  a sufficient  quan- 
tity of  quinine  to  protect  the  troops  exposed  to  malaria.  Owing  to  the  limited  supply, 
quinine  was  not  used  to  any  extent  as  a prophylactic  in  the  Confederate  Army,  and  in 
several  instances  where  the  attempt  has  been  made  to  use  it  thus,  it  has  failed  to  yield 
the  most  satisfactory  results,  from  its  irregular  and  unsystematic  employment.  It  appears 
that  it  is  very  difficult  to  induce  soldiers  to  take  quinine  in  the  state  of  powder.  The 
proper  mode  would  be  to  mix  the  quinine  with  whisky  (a  certain  number  of  ounces  to 
a barrel  of  whisky),  and  issue  the  medicated  whisky  at  a certain  hour  each  day,  in  the 
presence  of  officers  charged  with  the  duty  of  seeing  that  each  man  took  his  dose.  As  a 
general  rule,  soldiers  will  not  refuse  whisky,  even  when  it  contains  quinine.  Several 
instances  have  come  under  my  observation  where  medical  officers  serving  in  malarious 
localities  have  taken  quinine  daily  as  a prophylactic,  and  while  almost  the  entire  com- 
mand have  suffered  with  the  various  forms  of  malarial  fever,  they  have  escaped 
with  impunity.  In  the  summer  and  fall  of  1863,  during  the  great  changes  from  the 
Military  Department  of  Georgia  and  South  Carolina  to  Piedmont,  Virginia,  and  from 
thence  back  to  Carolina  and  Georgia,  and  during  considerable  exposure  to  malarious 
influence  in  localities  like  James  Island,  acknowledged  to  be  sickly,  I protected  myself 
with  quinine.  Doctor  J.  N.  Warren,  Assistant  Surgeon  of  the  Twenty-fifth  Regiment, 
South  Carolina  Volunteers,  stationed  on  James  Island,  S.  C.,  in  compliance  with  a 
request  which  I made  him  during  a visit  to  the  camps  on  James  Island  in  the  month  of 
April,  1863,  selected  two  hundred  men  from  the  regiment  and  administered  four  and  a 
half  grains  to  each  man  daily.  This  was  continued  regularly  until  the  1st  of  October, 
when  Dr.  Warren  was  transferred  to  Augusta.  During  this  period,  among  this  body  of 
men  only  four  cases  of  malarial  fever  and  one  case  of  typhoid  fever  occurred.  The 
remainder  of  the  regiment,  between  three  hundred  and  four  hundred  men,  did  not  take 


528  NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 

quinine  as  a prophylactic,  and  the  majority  of  these  men  were  attacked  by  paroxysmal 
fever;  and  over  three  hundred  cases  of  the  various  forms  of  paroxysmal  fever,  together 
with  twenty-three  cases  of  typhoid  fever,  occurred  among  them.  During  the  service  of 
this  regiment  at  Battery  Wagner,  the  men  who  took  quinine  daily  bore  the  fatigue 
better  and  resisted  the  deleterious  effects  of  the  climate  and  the  foul  air  of  the  bomb- 
proofs  better  than  those  who  did  not  thus  use  quinine. 

I received  from  Surgeon  Octavius  White,  C.  S.  A.,  in  1862,  a report  in  favor  of  quinine 
as  a prophylactic  against  malarial  fever,  and  also  from  Surgeon  Samuel  Logan,  Depart- 
ment of  South  Carolina  and  Georgia,  C.  S.  A.,  contributing  important  facts  illustrating 
the  prophylactic  powers  of  quinine,  and  from  Dr.  D.  Du  Pre,  of  Nashville,  Tenn.,  in 
1867,  in  which  he  recorded  instances  of  the  prophylactic  powers  of  quinine.  * 

In  the  use  of  quinine  as  a prophylactic  against  malarial  fever,  the  following  questions 
are  worthy  of  consideration  : — 

1.  To  what  extent  can  quinine  be  used  daily  as  a prophylactic  against  malaria 
without  inducing  any  injurious  effects  on  the  nervous  system? 

2.  How  long  can  quinine  be  used  daily  as  a prophylactic  against  the  effects  of  mala- 
rial fever  without  losing  its  power  or  without  inducing  injurious  effects  upon  the  human 
system  ? 

3.  What  proportion  of  the  entire  population  in  malarious  regions  could  be  preserved 
from  malarial  fever  by  the  use  of  quinine  as  a prophylactic? 

4.  What  effect  upon  the  total  mortality,  as  well  as  upon  the  number  and  character 
of  various  diseases,  would  the  prophylactic  use  of  quinine  induce  during  given  periods 
of  time  in  malarious  regions  ? 

5.  To  what  extent  can  arsenic  (arsenious  acid)  and  the  compounds  of  arsenicum  be 
substituted  for  quinine  for  the  prevention  of  malarial  fever? 

6.  What  effect  upon  the  human  organism  and  upon  the  character  and  number  and 
mortality  of  various  diseases  will  arsenic  produce  when  used  as  a prophylactic  ? 

The  preceding  questions  are  of  great  importance,  and  their  investigation  should 
demand  the  attention  of  the  medical  profession  in  all  malarious  regions.  Scientific 
commissions  of  experienced  and  accomplished  medical  men  should  be  appointed  by  the 
leading  powers  of  the  civilized  world  for  the  thorough  investigation  of  the  origin, 
nature,  propagation  and  prevention  of  the  morbific  ferment  of  malarial  fever.  To  be 
properly  constituted,  each  commission  appointed  by  the  individual  nations,  as  Great 
Britain,  Germany,  Spain,  Italy,  Austria,  Portugal,  Turkey,  Russia,  France  and  the 
United  States  should  be  constituted  thus : Chemist,  microscopist  (bacteriologist),  j 
botanist,  physiologist  (experimental),  hygienist,  therapeutist,  physician  (practicing,  of 
enlarged  experience  as  to  malarious  diseases).  The  first  duty  of  the  State  is  to  protect 
the  lives  of  the  laboring  classes  from  all  causes  of  preventable  diseases.  To  what  extent 
the  cause  of  malaria  may  be  removed  and  its  effects  modified  or  avoided,  can  only  be 
determined  by  the  careful  investigations  of  competent,  honest,  conscientious,  scientific 
men,  liberally  supplied  with  all  the  instruments,  reagents  and  processes  of  the  Nine- . I 
teeuth  century.  Whatever  the  results  of  such  labors  might  be,  they  will  illustrate  the 
humanity  as  well  as  the  science  of  the  civilization  of  the  pi’esent  day. 

DISCUSSION.. 

Dr.  Reed,  of  Mansfield,  0.,  said,  in  referring  to  Dr.  Jones’  paper,  in  which  he 
said  he  injected  swamp  water  hypodermically  in  animals,  producing  fever,  desired 
to  ask  the  question  whether  the  drinking  of  the  water  would  produce  the  same 
results  as  those  produced  from  the  use  of  the  hypodermic  syringe. 

* See  “ Medical  and  Surgical  Memoirs.”  By  Joseph  Jones,  m.  d.,  Vol.  ii,  pp.  1 122-1126.  New 
Orleans,  1887,  pp.  1348. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  529 


Dr.  Jones  replied  in  the  affirmative. 

Dr.  A.  N.  Bell,  of  New  York. — I have  heard  this  valuable  and  exhaustive 
paper  relating  to  the  investigations  of  the  author  during  the  past  thirty  years,  and 
am  gratified  to  know  their  history,  as  they  have,  to  a large  extent,  been  unknown  to 
the  American  profession. 

I have  been  especially  interested  in  those  parts  which  relate  to  the  following  sub- 
jects : namely — 

1.  The  chemical  and  microscopical  characters  of  the  blood  in  malarial  fever. 

2.  The  microscopical  appearances  and  changes  of  the  blood  in  malarial  fever. 

3.  The  comparison  of  the  chemical  and  microscopical  changes  of  the  blood  and 
organs  iu  yellow  and  malarial  fever. 

4.  The  results  of  injecting  swamp  water  subcutaneously  in  living  animals,  in  the 
years  1859  and  1860,  thus  anticipating  the  labors  of  subsequent  investigators  and 
demonstrating  its  poisonous  effects. 

5.  The  extensive  labors  relating  to  the  microscopical,  physical  and  chemical-  pro- 
perties of  soils  of  various  localities,  and  to  their  relations  with  the  origin  and  preva- 
lence of  malarial  fever. 

6.  The  discovery  in  1863,  during  the  siege  of  Charleston,  S.  C.,  of  the  microbe 
of  typhoid  fever. 

Dr.  Bell  said  that  this  paper  is  replete  with  chemical  and  microscopical  investiga- 
tions and  original  observations  of  great  practical  importance,  not  hitherto  placed 
within  reach  of  the  medical  profession. 

Dr.  Bell  proposed  that  the  thanks  of  the  Section  on  Public  and  International 
Hygiene  be  tendered  the  President  for  his  elaborate  and  valuable  paper. 

The  motion  was  put  to  the  Section  by  Dr.  Bell  and  unanimously  adopted. 


530 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


FOURTH  DAY. 


NATURE  OF  MALARIA  AND  PROPHYLAXIS  IN  MALARIAL 

REGIONS. 

NATURE  DU  POISON  PALUDEEN  ET  LA  PROPHYLAXIE  DANS  LES  PAYS 

INFECTES. 

UBER  DAS  WESEN  DES  MALARIAGIFTES  UND  DIE  PROPHYLAXE  IN  SUMPFGEGENDEN. 

BY  CORRADO  TOMMASI  CRUDELI,  M.D., 

Of  Rome,  Italy. 

Extracts  and  Translation  from  the  Italian,  by  Dr.  Felix  Formento, of  New  Orleans,  La* 

CAUSE  OF  MALARIA. 

It  is  well  known  tliat  eight  years  ago  Klebs  and  Tommasi  Crudeli  announced  to  the 
scientific  world  that  the  cause  of  malaria  was  a bacillus,  diffused  on  the  surface  of  the 
earth,  capable  of  retaining  its  vitality  for  a long  while  in  the  interior  of  the  ground, 
and  of  vegetating  in  soils  of  varied  geological  composition,  sometimes  paludal,  oftener 
wow-paludal,  provided  it  should  be  moderately  damp  in  the  hot  season  and  in  imme- 
diate contact  with  atmospheric  air.  During  these  eight  years  speculations  in  regard  to 
the  above  microorganisms  have  greatly  varied.  At  first,  there  were  many  confirma- 
tions of  its  existence.  Prof.  Cuboni  found  it  in  the  air;  Prof.  Ceci  in  the  soil  of  mala- 
rial regions;  Marchiafava,  Lanzi,  Perroncito,  Sciammana,  Fenaresi  and  Terrigi  found  it 
in  the  blood  of  fever  patients. 

At  first,  the  bacillus  malaria  was  always  found,  even  at  times  when  it  did  not 
exist,  confounding  with  it  accidental  products  in  the  blood,  due  to  alterations  of  blood 
globules  (pseudo-bacilli). 

“ These  pseudo-bacilli,”  Crudeli  says,  “I  have  always  considered  as  effect,  and  not 
cause,  of  malarial  infection,  and  can  he  produced  artificially.  In  fact,  these  alterations  of 
red  blood  globules  were  obtained  forty-five  years  ago.  Dujardin  described  and  designed 
perfectly  well  the  so-called  plasmodium  as  far  hack  as  the  year  1842,  producing  it  arti- 
ficially, either  by  preventing  evaporation  of  blood,  or  by  adding  to  it  weak  saline  solu- 
tion. 

‘ ‘ By  injecting  directly  into  the  abdominal  cavity  of  chickens  and  pigeons  the  blood  of' 
a dog,  after  three  days  there  will  be  found  in  its  red  globules  all  the  regressive  metamor- 
phoses which  have  been  interpreted  as  progressive  evolutions  of  a plasmodium.  These 
pseudo-plasmodium  result  from  a degeneration  of  the  red  globules,  which  maybe  deter- 
mined by  a variety  of  causes,  and  are  sometimes  found  in  typhus  fever,  progressive 
anaemia,  etc. 

“The  accurate  microscopical  researches  of  Marchiafava  and  Celli  induced  me  to 
believe  that  the  constant  presence,  in  notable  quantity,  of  black  pigment,  which  is  found 
in  the  degenerated  globules  of  malarial  patients,  could  be  considered  as  & pathognomonic 


* Translation  into  English  by  Dr.  Felix  Formento,  Italian  Secretary. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  531 


sign  of  malarial  infection,  and  I had  the  opportunity  to  illustrate,  in  1884,  at  the  Inter- 
national Congress  of  Copenhagen,  the  microscopical  preparation  of  Marchiafava  and 
Celli.” 

The  discoveries  of  Klebs  and  Crudeli  are  confirmed  hy  the  researches  of  Mosso  and 
Sehiavazzi,  and  more  recently  by  Prof.  Ferdinand  Cohn,  of  Breslau.  The  production 
of  malaria  is  not  necessarily  connected  with  the  existence  of  marshes  or  stagnant 
waters.  The  malarial  germ  is  entirely  different  from  the  putrid  germ  ; it  does  not 
develop  in  water,  but  in  tbe  ground.  In  hot  weather  it  develops  in  the  soil,  provided 
it  is  damp  and  in  contact  with  the  air,  while  there  is  no  trace  of  putrefaction  going  on 
in  said  soil ; once  carried  in  the  air  it  loses  its  virulence  by  being  diluted,  and  cannot 
be  infectious  beyond  a short  distance. 

Tommasi  Crudeli  prefers  filling  low  lands  with  dry  sand  or  earth  to  mechanical 
drainage.  Experiments  made  by  large  plantations  of  eucalyptus  (as  prophylaxis)  have 
not  given  the  results  that  were  expected,  as  has  been  demonstrated  by  the  experiments 
made  in  the  agricultural  colonies  of  The  Fontana. 

In  spite  of  unfavorable  conditions,  Rome  becomes  healthier  every  year,  on  account 
of  the  new  method  of  paving  streets,  which  is  gradually  being  extended  to  all  parts  of 
tbe  city. 

The  same  result  is  obtained  in  the  country  around  Rome  by  cultivation  of  artificial 
prairies  covered  with  thick,  dense  grass,  which  protects  the  soil  from  immediate  contact 
of  air,  which  condition  seems  indispensable  to  the  development  of  malaria,  being  at  the 
same  time  a great  advantage  to  agriculture.  Where  the  quality  of  the  soil  permits  the 
cultivation  of  wheat  and  the  vine,  malaria  still  continues  to  prevail,  in  spite  of  the 
improved  hydraulic  condition,  on  account  of  the  surface  of  the  soil  not  being  sufficiently 
protected. 

As  individual  prophylaxis  in  malarial  countries,  Crudeli  recommends  the  con- 
tinued use  of  small  doses  of  arsenic,  and  the  best  possible  alimentation.  Also,  the 
daily  use  of  decotion  of  lemons,  made  with  the  whole  fruit  and  taken  on  an  empty 
stomach. 

He  alludes  to  the  curative  properties  of  lemons,  and  mentions  the  fact  that  Professor 
Coloranti  and  Drs.  Leopold  Taussig  and  Oreste  Ferreire  have  used  it  with  excellent 
results  in  cases  of  malaria,  which  had  resisted  cjuinine,  some  in  their  own  families. 
He  mentions  that  it  has  also  been  tried  by  Dr.  Shakespeare,  in  the  Philadelphia  Hospi- 
tal. 

In  presenting  to  the  Royal  Accademia  dei  Lincei  of  Rome  numerous  specimens 
of  cultures  of  microorganism,  invariably  found  by  Dr.  Bernardo  Sehiavazzi  in  the 
malarial  atmosphere  around  Pola  (Istria)  and,  indicating  the  methods  of  observation 
followed  by  him  (Koch’s  apparatus  for  microphytic  investigations  of  the  atmosphere,  or 
simply  causing  the  air  to  pass  through  a tube  containing  five  centimetres  of  sterilized 
gelatine),  he  gives  as  follows  the  results  of  Dr.  Scliiavazzi’s  researches  : — 

1.  The  constant  presence  of  a bacillus,  morphologically  identical  to  that  described 
lry  Klebs  and  Crudeli,  under  the  name  of  bacillus  malaria,  in  the  malarial  atmosphere 
of  Pola,  and  its  absence  in  the  atmosphere  of  non-malarial  regions. 

2.  That  inoculation  of  pure  cultures  of  the  bacillus  in  rabbits  produces  fever  with 
all  the  characteristic  anatomical  and  clinical  symptoms  of  malarial  fever. 

3.  That  the  blood,  spleen  and  lymphatic  abdominal  glands  of  these  rabbits,  being 
placed  in  favorable  conditions  of  development,  furnish  an  abundant  vegetation  of 
bacilli  morphologically  identical  to  those  which  infected  the  rabbit. 

4.  That  in  animals  infected  by  pure  cultures  of  the  bacillus,  the  red  blood  globules 
undergo  those  alterations  described  by  Marchiafava  and  Celli  as  characteristic  of 
malarial  infection. 

5.  That  the  bacillus  has  been  found  in  the  waters  of  intensely  malarial  regions. 


532 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


From  tlie  above,  Schiavazzi  draws  the  conclusion  that  the  bacillus  found  by  him  is 
precisely  identical  with  the  bacillus  discovered  by  Klebs  and  Crudeli  in  1879,  and  that  it 
is  really  and  positively  the  cause  of  malaria. 

He  further  declares  that  malaria  increases  in  proportion  to  the  development  and 
presence  in  the  air  of  this  bacillus. 

Crudeli  passes  in  review  the  different  prophylactic  agents  that  have  been  recom- 
mended against  malaria,  particularly  quinine,  the  alkaline  salicylates  and  the  tincture 
of  eucalyptus.  Quinine  is  expensive  for  the  poor  peasants,  and  in  the  long  run,  disturbs 
the  digestive  and  nervous  functions.  The  salicylates,  when  pure,  are  also  expensive,  and 
observation  has  not  yet  proved  their  real  efficacy.  Tincture  of  eucalyptus  is  useful 
(like  all  alcoholic  stimulants),  rendering  more  active  the  circulation,  and  may  have 
succeeded  in  regions  of  country  where  malaria  is  not  very  severe,  but  does  not  succeed 
in  badly  infested  localities,  such  as  The  Fontana , where  terrible  epidemics  prevailed  in 
the  years  1880,  1882  and  1886,  in  spite  of  generous,  free  distribution  among  the  people 
of  a well-prepared  tincture. 

He  gives  the  preference  by  far  over  all  other  prophylactic  agents  to  arsenic  (arse- 
nious  acid),  which  possesses  more  permanent  anti-malarial  action,  costs  but  very  little, 
improves  nutrition,  and  can  be  administered  without  difficulty  to  all,  even  to  young 
children. 

The  preparation  which  is  recommended,  especially  among  ignorant  persons,  is  that 
of  accurately  dosed  gelatin  tablets,  each  containing  two  milligrammes  of  arsenious 
acid,  and  which  can  be  easily  detached,  one  from  the  other,  somewhat  like  our  postal 
stamp  sheets.  These  gelatin  tablets,  or  wafers,  are  easily  dissolved  in  coffee,  wine  or 
soup,  as  we  all  know  arsenic  should  never  be  given  on  an  empty  stomach.  It  should 
be  given  at  the  dose  of  two  milligrammes  a day  for  adults,  gradually  increased  to  twelve 
and  more  milligrammes.  It  can  be  given  without  danger,  for  three  and  four  months  at  a 
time,  with  occasional  short  intervals,  during  the  whole  period  of  danger,  from  June  to 
September,  inclusive.  Arsenic  may  be  administered  under  a different  name.  Its 
efficacy  as  a prophylactic  has  been  demonstrated  by  numerous  observations  (over  one 
thousand)  among  the  Contadine  soldiers  or  garrisons,  railroad  employes  living  in  the 
Agro  Romano. 

DISCUSSION. 

Dr.  R.  Walker,  of  Ind. — I would  like  to  ask  whether  Prof.  Crudeli  means  to 
say  that  the  stagnant  water  of  malarial  districts  does  not  contain  the  bacilli  of  malaria 
and  is  incapable  of  producing  that  disease  when  used  for  drinking  purposes  ? 

Dr.  Felix  Formento,  of  New  Orleans,  La.  (translator). — The  Professor  dis- 
tinctly says  that  the  bacillus  of  malaria,  the  cause  of  the  disease,  found  in  the  air  of 
malarial  regions,  has  also  been  found  in  water. 

Dr.  M.  K.  Taylor. — I have  a word  to  say  in  this  matter.  My  experience  at 
military  posts  on  the  plains  and  at  high  altitudes  has  led  me  to  regard  impure  water 
as  one  of  the  principal  means  by  which  the  malarial  poison  is  conveyed  into  the 
system. 

Dr.  D.  R.  Walker,  of  Ind. — I have  found  that  the  cause  of  malaria  in  my 
section  is  due  to  the  presence  of  stagnant  pools  of  water,  at  least  this  was  so  some 
years  ago,  but  now,  upon  the  draining  off  of  this  foul  water,  malaria  has  almost  dis- 
appeared, although  the  same  drinking  water  is  in  use  now  as  formerly. 

Dr.  Joseph  Jones,  of  New  Orleans,  La. — I discovered  many  years  ago  that  the 
injection  of  swamp  water  into  animals  produced  febrile  symptoms,  and  the  same 
changes  in  the  blood  as  noticed  in  malarial  fevers. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  533 


Dr.  B.  D.  Taylor. — My  experience  in  the  Northwest  has  led  me  to  adopt  the 
opinion  expressed  by  Dr.  M.  K.  Taylor,  for  I have  been  stationed  in  high  altitudes 
where  there  was  no  possible  way  to  account  for  the  malaria,  except  by  its  introduc- 
tion through  foul  drinking  water. 

Dr.  A.  R.  Milner,  of  New  Orleans,  La. — I believe  that  the  emanations  from 
the  water  may  be  hurtful,  but  not  the  water  itself. 

Dr.  R.  K.  Fox,  Jesuits’  Bend,  La. — I am  confident  that  the  bacillus  of  malaria 
does  not  exist  in  the  water  ; but  is  present  in  the  decaying  vegetable  matter  under 
the  water,  and  when  this  dries  up  the  emanations  from  the  filth  produce  the 
disease. 

Surgeon  M.  K.  Taylor,  m.d.,  of  the  United  States  Army,  said  he  would  not 
occupy  the  attention  of  the  Section  for  one  moment,  did  he  not  think,  indeed  feel 
certain,  that  the  paper  supported  by  the  great  name  of  the  author  was  calculated  to 
mislead  and  create  a false  impression  in  respect  to  drinking  being  a source  of  malarial 
poisoning.  The  history  of  our  military  posts  shows,  it  seemed  to  him,  conclusively, 
that  potable  water  is  frequently  a cause  of  the  malarial  fevers  of  every  form.  This 
is  apparent  at  stations  which  are  located  at  such  altitudes  as,  in  the  estimation  of  the 
profession,  and  in  popular  beliefs,  are  free  from  these  maladies — fallacies  of  the 
greatest  import. 

The  records  of  the  army  show  the  following  facts  : — 

Fort  Lewis  in  S.  W.  Colorado,  at  an  elevation  of  8000  feet  above  the  sea,  has 
a yearly  prevalence  of  malarial  fevers,  embracing  both  intermittent  and  remittent 
fevers,  above  the  average  of  the  whole  army.  Fort  Stanton,  in  New  Mexico,  situ- 
ated in  a region  of  country  known  for  its  arid  character,  has  had  these  fevers  in  large 
numbers,  from  its  establishment.  They  have  equaled,  for  years,  anywhere  from  20  to 
30  per  cent,  of  the  main  strength,  and  often  of  great  severity.  The  character  of  the 
water  supply  is  thus  described  by  the  post  surgeon:  “Water  insufficient,  offensive 
and  deficient.  It  is  taken  from  the  Rio  Bonito,  which  in  the  summer  runs  nearly 
dry,  and  which  is  contaminated  with  organic  matter.” 

Fort  Assinniboine,  in  Montana,  nearly  4000  feet  above  the  sea  and  close  to  the 
Canadian  line,  is  another  station  where  these  fevers  prevail.  The  water  supply  is 
from  a creek,  and  reported  by  the  Port  Surgeon  very  low,  deteriorated,  shows  organic 
matter  present,  deficient  and  very  offensive  ; water  should  be  boiled.  The  presence 
of  malarial  fevers  is  reported  at  Forts  Bayard,  Bridger,  D.  A.  Russell  and  many  others 
ranging  from  3000  to  6500  feet  above  the  sea  and  taking  the  water  supply  from 
streams  known  to  be  contaminated  by  the  wash  of  extensive  prairies,  and  often 
contaminated  by  Indian  camps  and  cattle  herds.  The  most  notoriously  malarial 
posts  are  those  taking  the  water  supply  from  streams.  Forts  situated  in  the 
Indian  Territory  are  examples  in  point.  Fort  Union,  New  Mexico,  taking  its  water 
supply  from  the  Arkansas  river,  is  situated  on  a terrace  30  feet  above  the  river 
bottom  and  upon  land  absolutely  barren  of  vegetation  except,  by  irrigation,  in 
small  amount,  and  Fort  Bliss,  in  northern  Texas,  taking  its  water  from  the  Rio 
Grande  and  situated  at  an  elevation  of  nearly  4000  feet  above  the  sea,  have  had 
malarial  fevers  very  prevalent,  at  the  latter  post  equaling  in  1873  the  rate  of  over  800 
per  thousand  of  mean  strength. 

The  records  show  further  that  whenever  there  has  been  a change  of  water  to  a 
better  quality  there  has  been  a corresponding  lessening  of  the  prevalence  of  these 
fevers,  more  than  50  per  cent.  At  Fort  Sill,  in  the  Indian  Territory,  the  change 
reached  over  50  per  cent,  in  changing  from  creek  water  to  a fine  quality  of  spring 


534 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


water,  while  at  Fort  Ringgold,  on  the  lower  Rio  Grande,  in  the  change  from  the 
natural  river  water  to  distilled  and  aerated  water  the  fevers  were  reduced  almost 
identically  in  the  same  ratio. 

The  facts  appearing  in  the  history  of  our  military  posts  are  overwhelming  in 
proof  that  potable  waters  may  be  a cause  of  miasmatic  disorders. 


THE  INFLUENCE  OF  CLIMATE  IN  THE  PRODUCTION  OF  CHOLERA 

INFANTUM. 

LTNFLUENCE  DU  CLIMAT  DANS  LA  CAUSALITE  DU  CHOLERA  DES  ENFANTS. 

UBER  DEN  EINFLUSS  DES  KLIMAS  IN  DER  ATIOLOGIE  DER  CHOLERA  INFANTUM. 

BY  GEORGE  TROUPE  MAXWELL,  M.D., 

Of  Ocala,  Florida. 

I acknowledge  a feeling  of  embarrassment  in  treating,  before  an  International  Congress, 
a subject  which,  in  its  practical  relations,  is  of  national  interest  chiefly.  But  I would 
feel  greater  hesitation  in  presenting  it  for  the  consideration  of  this  august  body,  com- 
posed of  sages  from  every  civilized  country,  did  I not  know  that  a disease  which  so 
deeply  affects  the  welfare  and  happiness  of  a large  portion  of  the  human  family  must 
have  at  least  a scientific  attraction  for  all  medical  philosophers. 

The  cause  and  prevention  of  a disease  which,  though  it  assails  only  one  class — 
children  of  the  tenderest  ages,  and  does  its  deadly  work  principally  in  a single  month,  but 
which,  in  the  long  catalogue  of  “ ills  that  flesh  is  heir  to  ” stands  sixth  in  the  order 
of  fatality,  and  annually  numbers  as  its  victims  more  than  thirty  thousand  in  the 
United  States,  demand  the  earnest  attention  of  philanthropists,  and  are  worthy  of  the 
most  careful  consideration  of  scientists. 

Nothing,  perhaps,  more  clearly  demonstrates  the  fact  that  familiarity  with  danger, 
suffering  and  death,  as  with  vice,  blunts  human  sensibility,  than  the  conduct  of  men  in 
contact  with  disease.  In  the  presence  of  yellow  fever,  for  instance,  the  inhabitants  of 
towns  and  cities  within  the  territorial  area  to  which  it  is  indigenous  display  compara- 
tively little  terror  in  the  midst  of  its  work  of  destruction,  while  even  suspicion  of  its 
probable  invasion  of  communities  unused  to  its  ravages  affrights  them  into  unseemly 
and  even  tumultuous  panic. 

We  had  an  illustration  of  this  the  last  summer,  when  entire  communities  in  parts 
of  our  country  were  thrown  into  liysteroid  tremors  because  of  a few  cases  of  yellow 
fever  upon  a small  island  nearly  a hundred  miles  from  the  main;  while  the  better 
classes  of  the  little  town  that  had  stirred  this  commotion  were  energetically  engaged  in 
laudable  efforts  to  suppress  gambling  and  other  vices  that  were  rampant  in  the  atmos- 
phere of  pestilence. 

And  while  that  exhibition  of  indifference  to  yellow  fever — the  summer  scourge  of 
low  latitudes — was  being  given  in  the  southern  extreme  of  our  country,  and  Key  West 
was  being  shunned  as  a plague-spot,  cholera  infantum— the  summer  scourge  of  high 
latitudes — was  daily  counting  its  victims  among  the  innocents  by  thousands,  with  little 
more  remark  than  as  a news  item  in  the  daily  papers. 

Pestilence,  in  whatever  garb  itassumes,  is  appalling,  seemingly,  only  to  those  who  are 
unaccustomed  to  its  devastation;  while  in  communities  which  are  often  its  field  of 
slaughter,  it  is  regarded  as  a matter  of  course,  not  calculated  to  excite  especial  wonder. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  535 


I have  thought  that,  in  this  way,  perhaps,  the  routine  and  perfunctory  style  of 
writers  in  general  upon  cholera  infantum  may  he  explained.  With  rare  exceptions  the 
doctrines  of  recent  writers  have  come  down  to  us  from  former  generations  without 
change  or  modification;  and  the  same  sad  uusuccess  which  resulted  from  the  treatment 
practiced  by  the  fathers  follows  the  same  inadequate  measures  which  are  employed  by 
the  wisest  of  to-day.  Familiar  with  its  destruction,  as  with  the  recurring  years  it 
heralds  the  approach  of  black- winged  death  to  thousands  of  households,  it  is  too  gener- 
ally regarded  as  an  inevitable  evil  which,  as  it  “can’t  be  cured,  must  be  endured.” 

An  instance  of  marching  out  of  the  beaten  track  in  dealing  with  the  aetiology  and 
prophylaxis  of  cholera  infantum,  was  furnished  by  Dr.  Davis,  of  Chicago,  the  distin- 
guished president  of  this  Congress,  in  an  instructive  essay  which  he  read  before  the 
section  on  “ Diseases  of  Children,”  of  the  American  Medical  Association,  at  Detroit,  in 
1882.  Not  satisfied  with  the  theories  commonly  accepted  as  orthodox,  that  careful 
observer  and  sagacious  physician  showed  by  facts  and  figures  that  the  causes  usually 
assigned  as  chiefly  instrumental  in  the  production  of  cholera  infantum  exert,  if  they 
operate  as  factors  at  all,  only  a “minor  influence.” 

Said  he : “ Nearly  all  the  recent  writers  on  practical  medicine  and  diseases  of  children 
class  the  cases  of  serous  diarrhoea  and  cholera  morbus  in  children  under  two  years  of  age, 
usually  called  summer  complaint  and  cholera  infantum,  with  the  local  inflammations, 
under  the  general  head  of  catarrhal  gastro-enteritis.  And  while  they  all  assert  that 
these  forms  of  disease  are  most  prevalent  and  fatal  during  the  warmest  months  of 
summer,  they  set  forth  as  the  chief  causes,  improper  feeding,  impure  and  changed  milk, 
impure  and  confined  air,  the  progress  of  dentition  or  ‘teething,’  and  overworked, 
badly  fed  and  unhealthy  mothers  and  nurses.  All  these  causes  are  set  forth  as  pro- 
ducing either  gastric  or  intestinal  indigestion,  or  both.  It  will  be  noted  that  indigestion 
is  very  generally  alleged  as  the  immediate  cause  of  the  so-called  catarrhal  irritation  and 
excessive  discharges,  while  the  indigestion  is,  in  turn,  regarded  as  the  result  of  bad  feed- 
ing, impure  air,  teething,  and  unhealthy  mothers  and  nurses.  Dr.  Flint  and  others  have 
placed  much  emphasis  on  the  influence  of  adulterated  and  poor  quality  of  milk  dis- 
tributed in  our  large  cities.  That  the  milk  so  distributed  is  often  of  poor  quality,  and 
is  often  productive  of  gastric  and  intestinal  derangements,  and  that  all  the  other  causes 
enumerated  are  often  the  occasion  of  similar  derangements,  I freely  admit.  But  I am 
quite  certain  that  a more  careful  and  extended  clinical  study  will  show  that  some  of  the 
causes  usually  enumerated  rarely  exert  more  than  a minor  influence  over  the  so-called 
summer  complaint  and  cholera  infantum  that  prove  so  destructive  to  infantile  life  in 
many  of  our  large  cities  and  populous  towns  every  summer.  For  instance,  a moderate 
degree  of  attention  will  show  that  the  errors  in  feeding  infants,  the  adulterations  of  milk 
and  impurities  of  other  food,  and  the  unsanitary  condition  of  dwellings  are  quite  as 
prevalent  in  all  communities  during  the  winter  as  the  summer.  It  is  quite  certain  that 
on  the  average  there  are  in  all  communities  as  many  children  cutting  their  teeth 
in  December  and  January  as  in  July  and  August,  and  I have  been  wholly  unable  to 
find  any  larger  proportion  of  unhealthy,  badly  fed,  or  overworked  mothers  or  nurses  at 
one  part  of  the  year  than  another.  It  is  very  certain  that  if  any  one  or  all  of  these 
agencies  exercised  a prominent  or  controlling  influence  in  determining  attacks  of  serous 
diarrhoea  and  cholera  infantum,  such  attacks  would  be  met  with  frequently  at  all 
seasons  of  the  year.  Yet  both  the  records  of  commencements  of  attacks  and  the  statis- 
tics of  mortality  show  that  the  prevalence  of  all  grades  of  these  two  forms  of  disease  is 
restricted  almost  entirely  to  the  ninety  days  intervening  between  the  last  week  in  June 
and  the  last  in  September. 

“Thus,  in  Chicago,  in  1877,  only  two  deaths  from  cholera  infantum  are  reported  in 
the  statistics  of  the  Heal  th  Department  during  the  months  of  November,  December, 


536 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


January,  February  and  March,  eight  in  April,  six  in  May,  23  in  June,  246  in  July,  163 
in  August,  69  in  September,  and  13  in  October. 

“ Again  in  1875  and  1876  I obtained  the  date  of  the  commencement  of  351  cases  of 
serous  diarrhoea  and  cholera  infantum,  of  which  61  commenced  in  June,  197  in  July, 
66  in  August,  and  27  in  September,  and  none  during  the  remaining  months  of  these 
years.  The  ratio  of  prevalence  thus  found  to  exist  in  the  various  months  of  1875-6-7, 
in  Chicago,  will  be  found  to  fairly  represent  the  ratio  every  year,  and  in  all  the  northern 
and  eastern  cities  of  our  country. 

“If  we  turn  our  attention  in  another  direction,  we  will  be  met  by  still  greater  diffi- 
culties in  accounting  for  these  bowel  affections,  on  the  supposition  that  they  are  produced 
by  the  causes  to  which  they  have  usually  been  attributed.  For  instance,  the  mortuary  sta- 
tistics show  that  the  diseases  under  consideration  prevail  but  little  in  cities  so  located  that 
there  is  only  a short  range  of  temperature  between  the  warmest  days  of  summer  and  the 
coldest  days  of  winter,  and  where  from  sea  breezes,  or  otherwise,  the  summer  nights  are 
cool. 

‘ 1 There  is  no  evidence,  within  our  knowledge,  which  shows  that  the  milk  distributed 
in  San  Francisco  and  New  Orleaus,  is  any  purer  or  of  better  quality  than  in  Boston  and 
Chicago.  Neither  are  nursing  mothers  any  more  free  from  mental  and  physical  infirmi- 
ties, nor  the  sanitary  condition  of  the  dwellings,  sewers,  etc. , more  perfect,  in  the  former 
than  in  the  two  last  named  cities.  Yet  an  examination  of  the  mortality  statistics  shows 
a ratio  of  only  about  five  deaths  from  cholera  infantum,  annually,  for  every  10,000 
inhabitants  in  San  Francisco;  and  seven  in  New  Orleans;  while  Boston  gives  25  and 
Chicago  30  deaths,  from  the  same  cause,  for  every  10,000  inhabitants. 

“The  foregoing  facts  show  conclusively  that  there  must  be  some  efficient  cause  or 
causes  which  determine  the  prevalence  of  the  disease  under  consideration  that  are  not 
common  to  all  large  cities,  and  all  aggregations  of  civilized  people.  Their  prevalence 
at  certain  seasons  of  the  year  only,  and  chiefly  in  certain  climatic  regions,  shows  con- 
clusively that  they  are  dependent  on  causes  which  are  operative  under  some  circum- 
stances not  common  to  all  civilized  communities.” 

Dr.  Davis  began  years  ago  an  investigation  to  ascertain  what  those  circumstances 
are.  The  most  important  of  his  conclusions  are  : 1.  “ That  the  disease  commences  with 
the  first  wave  of  atmospheric  heat  that  continues  day  and  night  for  five  successive 
days.  ” 2.  “ That  the  date  of  the  initial  symptoms,  or  beginning  of  the  disease,  in  three- 
fourths  of  all  the  cases  is  in  July,  very  few  originating  in  August.”  And  3,  “ that  if  in 
addition  to  high  heat,  the  air  be  stagnant,  as  from  lack  of  winds,  or  from  obstructions, 
as  in  large  and  compactly  built  cities,  or  from  defective  ventilation  of  dwellings,  the 
morbific  effects  are  greatly  increased.” 

I have  drawn  freely  upon  the  admirable  essay  of  Dr.  Davis,  because  his  utterances 
on  all  medical  subjects  carry  with  them  the  weight  which  belongs  to  supreme  authority, 
but  principally  because  his  statement  of  facts,  as  they  bear  upon  the  retiologyof  cholera 
infantum,  and  the  inferences  he  draws  from  them,  are  in  precise  accord  with  my  own 
experience  with  the  disease  and  my  deductions  from  observation  of  it  in  its  chosen 
“climatic  regions,”  during  nine  years.  Dr.  Davis  has,  I think,  conclusively  demon- 
strated the  fallacy  of  the  prevailing  theories,  and  I have,  for  convenience,  appropriated 
his  demonstration.  But,  while  I am  in  agreement  with  him  in  detracting  from  the 
alleged  importance  of  the  agencies  enumerated  by  writers  in  general  as  productive  of 
cholera  infantum,  and  in  attributing  to  them  a minor  influence,  if  any,  I find  it  impos- 
sible to  coincide  with  him  in  the  hypothesis  which  he  lias  constructed,  and  offered  as  a 
substitute.  Clearly  and  conclusively  as  Dr.  Davis  has  proven  that  not  improper  feeding, 
adulterated  and  changed  milk,  but  hygienic  conditions,  impure  air.  overworked,  diseased, 
improperly  and  insufficiently  fed  mothers  and  nurses,  teething  and  indigestion,  one,  or 
all,  will  satisfactorily  account  for  the  general  prevalence  and  appalling  fatality  of  cholera 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  537 

infantum  annually  in  tlie  northern  sections  of  our  country,  the  proof  is  equally  absolute 
that  intense  heat,  long  continued,  and  low  range  of  temperature,  even  when  reinforced 
by  so-called  “stagnant  air,”  are  not  the  efficient  causes.  Dr.  Davis  has  shown  by 
mortuary  statistics,  and  by  his  personal  investigations,  that  July  is  the  especial  delin- 
quent— more  than  three-fourths  of  the  cases  beginning  in  that  month.  This  is  not,  so 
to  speak,  accident.  It  is  the  rule;  and  there  must  be  reason  for  it.  If  continuous, 
high  heat,  through  successive  days  and  nights,  associated  with  stagnant  air,  is  indeed 
the  causa  causans  of  cholera  infantum,  it  must  appear  that  such  meteorological  condi- 
tions are  distinguishing  characteristics  of  that  month.  Is  that  the  case  ? Let  us  see. 

There  were,  at  Chicago,  in  1886,  13  days  in  which  the  temperature  reached  80°  and 
above;  in  August  there  were  14.  In  July  there  were  two  groups  of  three  successive 
days  in  which  the  temperature  reached  80°  and  above,  one  being  of  five  days 
duration ; in  August  there  were  three  similar  groups  of  successive  hot  days, 
one  continuing  four  days  and  another  five.  The  longest  continuance  of  hot 
days,  with  a break  of  a single  day,  was,  in  July,  six,  the  mercury  descending  one  day 
to  76.3°;  in  August,  ten,  the  mercury  falling  one  day  to  79°.  The  sum  of  the  temper- 
ature of  the  (13)  hottest  days  in  July  is  1114.2°;  in  August,  the  sum  of  the  (14)  hottest 
days  is  1198.4°,  a difference  of  84°.  The  mean  daily  range  of  temperature  was,  in  J uly, 
13  9°;  in  August,  12.2°.  The  least  daily  range  of  temperature  was,  in  July,  5.6°;  in 
August,  4 .2°.  August  was,  therefore,  the  hotter  month,  with  a greater  number  of  and 
longer  lasting  groups  of  successive  hot  days;  with  lower  mean  and  daily  range  of  tem- 
perature; and  followed  June  and  July  with  their  protracted,  intense  heat.  Besides, 
the  records  show  that  there  was  more  movement  of  wind  in  July  than  in  August  ; or, 
in  other  words,  that  the  air  was  more  stagnant  in  the  latter  than  in  the  former  month. 
There  having  been  5472  miles  of  movement  in  July,  and  5439  in  August. 

With  higher,  and  longer  continuance  of  heat,  and  a calmer  air  in  August  than  in 
July,  the  former  ought,  according  to  Dr.  Davis’  hypothesis,  to  furnish  a larger  mortality 
list;  but,  on  the  contrary,  the  statistics  show  285  deaths  from  cholera  infantum  in  July, 
and  201  in  August,  a difference  of  84,  which  disparity  would  be  greatly  increased  if 
three-fourths  of  the  cases  that  died  in  August  were  charged  to  July,  when  they 
undoubtedly  had  their  beginning.  It  is  logically  impossible  to  explain  the  high 
annual  mortality  from  cholera  infantum  in  July,  and  the  great  and  sudden  decrease  in 
the  number  of  deaths  in  August,  by  the  hypothesis  of  Dr.  Davis. 

Again,  if  we  attribute  the  comparative  immunity  of  San  Francisco,  New  Orleans 
and  other  large  cities  in  warm  climates,  to  their  locations  near  the  coast,  and  the 
hygienic  effect  of  sea  breezes  by  day,  and  cool  breezes  at  night,  how  will  we  account 
for  the  great  mortality  from  cholera  infantum  in  Boston,  New  Haven,  New  York, 
Brooklyn  and  all  other  towns  and  cities  of  the  Eastern  and  Middle  States  similarly 
situated.  Statistics  are  abundant  to  show  that  the  cities  named  have  an  annual  experi- 
ence of  the  prevalence  and  fatality  of  cholera  infantum  which  is  common  to  all  the 
towns  and  cities  within  certain  “ climatic  regions.” 

And  again,  if  it  be  true  that  the  range  of  temperature  between  the  hottest  days  of 

I summer  and  the  coldest  of  winter  enters  as  an  element  in  the  production  of  cholera 
infantum,  that,  as  asserted,  the  higher  the  range  the  greater  the  prevalence  and  mor- 
tality, and  vice  versa;  St.  Paul  and  Denver,  with  their  much  higher  range  than 
Chicago  and  Cincinnati,  ought  to  exhibit  a correspondingly  great  ratio  of  prevalence 

I and  fatality.  But  the  reverse  obtains.  The  deaths  from  cholera  infantum  in  St.  Paul, 
lor  the  year  1880,  were  17;  in  Denver,  27;  while  they  were  for  the  same  year,  in 
Chicago,  555;  in  Cincinnati,  204.  No;  I repeat,  not  improper  feeding,  changed  and 

I adulterated  milk,  bad  hygienic  conditions,  impure  air,  overworked,  diseased,  Improp- 
erly and  insufficiently  fed  mothers  and  nurses,  teething  and  indigestion,  nor  long  con- 
tinued, intense  heat  with  stagnant  air,  one,  or  all,  satisfactorily  accounts  for  the  preva- 


538 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


lence  and  fatality  of  cholera  infantum  in  the  northern  sections  of  our  country.  The 
cause  has  yet  to  be  discovered. 

But  the  most  flagrant  error  which  Dr.  Davis,  in  common  with  all  writers  upon  the 
subject,  makes,  is  that  cholera  infantum  is  less  prevalent  and  less  fatal  in  rural  districts 
within  the  climatic  regions  to  which  it  belongs  than  in  large  and  densely  populated 
cities.  This  error  is  the  more  important  and  serious  because  it  has  led  to  all  the  mis- 
takes that  have  been  committed  on  the  questions  of  aetiology  and  prophylaxis. 

I had  practiced  medicine  twenty-three  years  in  the  extreme  .Southern  section  of  the 
United  States,  when,  in  June,  1871,  I moved  to  the  State  of  Delaware.  During  that 
time  I had  only  occasionally  seen  cases  of  cholera  infantum.  I located  at  Middletown, 
a village  of  about  one  thousand  inhabitants,  the  centre  of  prolific  peach  orchards,  in 
a beautiful,  thickly-settled,  highly-improved  farming  country,  midway  between  the 
Chesapeake  and  Delaware  Bays.  I soon  discovered  that  my  practical  knowledge  of 
cholera  infantum  was  meagre  and  imperfect ; for  I believe  I am  within  the  bounds  of 
truth  when  I say  that  I saw  a greater  number  of  cases  in  that  village  and  its  vicinity 
within  three  months  than  I had  previously  seen  in  twenty-three  years. 

The  town  of  New  Castle,  Delaware,  is  located  on  the  Delaware  River,  at  the  head 
of  Delaware  Bay.  It  is  not  compactly  built,  has  neither  over-crowded,  illy-ventilated 
tenement  houses  nor  squalid,  filthy  poor,  and  is  freely  exposed  to  river  and  sea  breezes. 
With  a population  of  about  two  thousand,  there  were  buried  in  its  cemetery  in  the 
month  of  July,  1873,  forty-one  children  under  three  years  of  age,  victims  of  cholera 
infantum.  In  comparison  with  these  figures,  Boston’s  twenty-five  and  Chicago’s  thirty 
to  ten  thousand  inhabitants  pale  into  insignificance.  In  a letter  from  Dr.  Benjamin 
Lee,  the  distinguished  Secretary  of  the  State  Board  of  Health  of  Pennsylvania,  of  July 
27th,  1887,  he  says:  “I  was  informed,  when  recently  in  the  Wyoming  Valley,  this 
State,  by  a leading  physician  in  large  practice  in  the  mining  villages  that  cholera 
infantum  was  very  prevalent,  and  often  rapidly  fatal,  in  that  region.” 

Nothing  like  what  I have  related  of  Middletown  and  New  Castle,  Delaware,  facts 
of  my  personal  observation,  and  what  has  been  said  by  Dr.  Lee,  has  ever  been  known 
in  any  Southern  city  or  town.  And  it  is  only  by  contrasting  those  facts  with  our 
experience  in  the  far  South  that  we  can  approach  a just  conception  of  what  a fearful 
scourge  cholera  infantum  is  at  the  North. 

Ocala  is  located  in  the  centre  of  the  peninsula  of  Florida.  It  is  about  equidistant 
— fifty  miles — from  the  Atlantic  and  the  Gulf.  It  has  about  2500  inhabitants,  and, 
without  special  favoring  circumstances  as  to  breezes  and  hygienic  conditions,  it  is 
entirely  exempt  from  cholera  infantum.  During  the  last  six  summers  I have  resided 
and  practiced  medicine  there,  and  have  not  seen  or  heard  of  a case  of  that  disease. 
Nor  is  the  experience  of  Ocala  peculiar.  Dr.  Hicks,  the  health  officer  of  Orlando,  Fla., 
wrote  to  me  that  “cholera  infantum  is  almost  unknown  here.”  And  from  personal 
knowledge  I can  say  the  same  of  Fernandina  and  Tallahasse.  At  Jacksonville  the 
proportion  of  deaths  from  cholera  infantum,  to  10,000  inhabitants,  was,  in  1880,  6;  in 
1881,  12;  and  in  1882,  5.  At  Savannah,  Ga.,  the  mortuary  report,  as  published  in 
The  Savannah  Journal  of  Medicine,  Sept.,  1876,  shows  only  one  death,  in  July  and  August 
each,  from  cholera  infantum;  and  the  cemetery  records  of  Thomasville,  Ga.,  from  1881 
to  August  27th,  1887,  show  but  two  deaths  from  that  disease. 

It  thus  appears  that  cholera  infantum  has  its  chief  home  in  certain  climatic  regions, 
and  within  the  territorial  area  which  furnishes  the  conditions  for  the  production  of  its 
cause  it  prevails  among  the  rich  as  well  as  the  poor,  in  palatial  residences  as  well  as  in 
crowded  tenements  and  filthy  cabins,  in  towns,  villages,  hamlets  and  isolated  farm- 
houses, as  well  as  in  compactly  built,  densely  populated,  insanitary  cities.  More;  in 
the  territorial  area  within  which  cholera  infantum  prevails  neither  topographical  nor 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  539 


other  physical  features  of  localities  exert  appreciable  restraining  influence;  for  its  deadly 
work  is  done  at  the  seashore,  on  elevated  plateaus  and  upon  mountains. 

The  cause  has  yet  to  be  discovered;  hut  the  patent,  significant  fact  remains — that, 
whereas  it  is  a terrible  scourge  at  the  North,  it  is  an  infrequent  and  comparatively 
trifling  affection  at  the  South;  and,  as  Dr.  Davis  has  said,  “Its  presence  at  certain 
seasons  of  the  year  only,  chiefly  in  certain  climatic  regions,  shows  conclusively  that  it 
is  dependent  upon  some  circumstances  not  common  to  all  civilized  communities.” 
What  are  those  causes  ? 

Cholera  infantum,  like  yellow  and  typhoid  fevers,  Asiatic  cholera,  etc.,  is  a specific 
disease,  and  has  a special  and  peculiar  cause.  It  is  not  a gastro-enteritis,  such  as  results 
from  indigestible  or  fermented  food,  or  from  acrid  poisons,  like  arsenic  and  tyrotoxicon. 
It  is  the  effect  of  a specific  poison  which  produces  cholera  infantum,  and  nothing  else. 
In  the  present  status  of  aetiological  science  it  is  a reasonable  assumption  that  the  special 
cause  is  a microorganism  which  exists  and  propagates  under  suitable  conditions  of  cli- 
mate, such  as  are  present  during  the  summer  in  the  Northern,  Eastern  and  Middle 
States  of  the  United  States. 

As  the  germ  of  yellow  fever  finds  its  favorite  home  in  tropical  and  semi-tropical 
America,  and  the  germ  of  Asiatic  cholera  its  appropriate  nidus  in  India,  so  the  germ  of 
cholera  infantum  makes  its  habitat  in  the  Northern  and  Eastern  States  of  our  Union. 
That  their  appearance  is  synchronous  with  the  approach  of  the  “heated  term,”  that 
their  numbers  and  power  for  evil  should  culminate  in  J uly,  or  midsummer,  is  not  more 
remarkable,  or  inconsistent  with  natural  laws,  than  for  flowers  to  have  their  time  to 
bloom,  and  fruits  theirs  to  mature;  and  it  would  be  easy  to  find  analogies  throughout 
the  animal  kingdom. 

As  the  theories  of  the  chemical  origin  of  the  malarial  poison  have  been  made  to 
give  place  to  the  microscopic  demonstrations  of  the  malarial  bacillus,  by  the  world- 
renowned  Tomassi  Crudeli,  so  the  chemico-physical  hypotheses  of  the  aetiology  of 
cholera  infantum  must,  in  their  turn,  he  supplanted  by  the  soon-to-be-discovered  bacil- 
lus of  cholera  infantum.  By  this  suggestion,  if  it  has  not  been  done  before,  the  way  is 
opened  to  some  enterprising  American  to  share,  with  Klebs,  Tomassi  Crudeli,  Koch  and 
others,  the  distinguished  honor  which  the  world  is  ever  ready  to  bestow  upon  those  who 
are  at  once  discoverers  and  benefactors. 

The  immunity  from  cholera  infantum  which,  as  the  records  show,  the  Gulf  and  the 
Pacific  States  enjoy,  must  arrest  attention,  and  whether  the  explanation  I have  given 
is  the  correct  one,  or  not,  the  fact — patent  and  significant — remains;  and  I believe  that 
when  the  fact  is  known  and  appreciated,  the  South  will  become  to  the  innocents  what 
the  “cities  of  refuge”  were  to  the  Levites,  to  which  thousands  will  be  brought,  to  escape 
the  merciless  child  slayer  ; for  as  certainly  as  the  middle-aged,  with  weak  or  diseased 
respiratory  organs,  are  now  induced  to  come  in  winter,  will  parents  he  influenced  by 
their  medical  advisers  to  take  their  infants  and  young  children  to  the  far  South  in  the 
summer,  to  avoid  the  ravages  of  this  cruel  pestilence. 

There  is  one  point  which  I ask  permission  to  refer  to  before  concluding,  simply  as  a 
suggestion  to  those  who  have  more  industry  and  better  facilities  for  investigation  than 
I.  It  is  this:  During  my  observation  of  cholera  infantum,  circumstances  led  me  to 
suspect  that  the  fatality  of  the  disease  has  been  appreciably  increased  by  the  introduc- 
tion and  universal  use  of  the  child’s  carriage.  Every  one  knows — by  observation,  if  not 
by  experience — how  aggravating  to  every  form  of  irritation  of  the  stomach  and  bowels  is 
agitation  of  the  body;  yet  who  has  not  seen — and  often  in  the  dead  hours  of  the  night 
heard — the  incessant  rolling  of  the  carriage,  with  its  restless,  suffering  cargo,  over  the 
uneven  sidewalks  of  cities  ? I am  quite  sure  that  I have  seen  fatal  results  hastened,  if  not 
caused,  by  a single  night  of  sucli  kindly-intended  but,  nevertheless,  rough  treatment. 
In  no  class  of  diseases  is  the  benign  influence  of  rest  more  imperatively  demanded. 


540 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


DISCUSSION. 

Dr.  R.  Harvey  Reed,  of  Ohio. — It  is  well  known,  Mr.  President,  that  children 
nursed  on  the  bottle  are  much  more  liable  to  cholera  infantum  than  those  nursed  by 
their  own  mothers.  The  nursing  bottles  with  long  tubes  are  especially  liable  to 
produce  this  affection,  from  the  fact  of  the  difficulty  experienced  in  cleaning  them. 

I never  allow  anything  to  be  used  except  an  open  bottle  with  a rubber  nipple  pulled  ) 
over  the  top,  and  which  can  readily  be  cleaned.  The  Doctor  speaks  of  the  disease  | 
being  most  prevalent — contrary  to  the  popular  idea — in  the  country ; but  who  knows  ■ 
that,  as  far  as  the  cleanliness  of  the  milk  is  concerned,  the  same  conditions  may  not 
prevail  in  the  small  hamlet  as  in  the  crowded  city. 

Dr.  B.  D.  Taylor. — I would  like  to  ask  the  Doctor  how,  on  his  theory,  he 
accounts  for  the  prevalence  of  cholera  infantum  in  Texas?  I have  seen  it  frequently 
in  the  summer  months,  both  at  Brackettville  and  Rio  Grande  City,  Texas. 

Dr.  G.  Troupe  Maxwell,  of  Florida. — I am  not  able  to  give  a satisfactory 
answer  to  that  question,  as  I have  no  statistics  from  Texas. 

Prof.  Victor  C.  Vaughn,  of  Michigan. — I have  not  specially  attached  myself 
to  this  Section,  but  I am  compelled  to  make  a few  remarks  on  this  question.  It  is 
one  of  the  best-established  facts  of  the  profession  that  children  nursed  by  their  own 
mothers  or  wet  nurses  seldom  have  cholera  infantum,  while  it  is  well  known  that 
infants  raised  on  the  bottle  suffer  the  greatest  mortality.  I am  unable  to  see  how 
it  can  be  disputed  that  the  decomposition  of  the  milk  and  the  formation  of  a 
ptomaine  is  the  chief  and  most  potent  cause  of  cholera  infantum.  The  post-mortem 
appearances  after  poisoning  by  a ptomaine  and  death  from  this  disease  are  precisely 
similar,  particularly  the  appearance  of  the  stomach.  Take  away  the  milk  from  the 
child  and  give  it  beef  tea  and  it  at  once  improves,  and,  as  a rule,  ultimately  recovers. 

It  is  easy  for  men  who  have  seen  little  of  this  disease  to  formulate  theories  as  to  its 
nature  and  origin ; but  it  is  with  those  who  have  treated  and  are  treating  it  by  hun-  1 
dreds  of  cases  every  summer  to  frame  rational  ideas  of  its  aetiology  and  practical 
ideas  as  to  its  treatment. 

Dr.  Joseph  Jones,  of  New  Orleans,  La. — I consider  the  irritation  of  the  teeth 
pressing  against  the  dental  nerves,  and  causing  reflex  action  to  the  spinal  column  and 
sympathetic  nerve  centres,  to  be  one  of  the  causes  of  cholera  infantum.  In  every- 
thing concerning  the  origin  and  cause  of  cholera  infantum,  we  must  carefully  consider 
the  peculiar  state  of  the  nervous  system  in  this  disease.  The  irritation  of  the  dental 
nerves  causes  by  reflex  action  the  irritation  of  the  stomach  and  bowels,  resulting  in 
enfeebled  digestion  and  diarrhoea.  Even  the  kidneys  show  the  influence  of  reflex 
action  from  the  spinal  cord  in  the  increased  flow  of  urine,  which  sometimes  contains 
grape  sugar.  We  are  all  familiar  with  the  celebrated  experiments  of  Claude  Bernard, 
in  the  production  of  diabetes  mellitus  in  animals  by  the  artificial  irritation  of  the 
medulla  oblongata  and  spinal  cord.  Dr.  Jones  had  frequently  demonstrated  the  truth 
of  Bernard’s  statements  by  experiments  on  living  animals.  The  frequency  and  fatality 
of  convulsions  in  teething  children  is  also  another  proof  of  the  irritated  and  deranged 
condition  of  the  cerebro-spiual  and  sympathetic  systems  in  this  troublesome  and  fatal 
form  of  disease. 

Dr.  Jones  suggested  that  the  cause  of  the  greater  virulence  of  the  disease  in  July 
might  be  referred  to  the  debilitating  effects  of  high  heat  upon  the  deranged  and 
debilitated  system  of  teething  children.  The  first  spells  of  high  and  protracted  heat 
usually  occur  in  this  month,  and  the  feeblest  children  soonest  succumb  to  its  well- 
known  effects.  As  the  summer  wears  on,  the  system  becomes  accustomed  to  its  effects 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  541 

Along  the  Atlantic  and  G-ulf  coasts  of  our  Southern  States,  with  their  insular  cli- 
mates, the  cold  of  winter  and  the  heat  of  summer  are  modified,  and  the  seasons  glide, 
as  it  were,  into  each  other  by  almost  insensible  degrees.  In  New  York,  Philadelphia, 
Cincinnati  and  Chicago,  the  extremes  of  heat  and  cold  are  much  greater  and  more 
rapid,  and  hence  the  effects  of  great  extremes  of  heat  are  more  marked.  In  Cincin- 
nati and  Chicago  especially  we  have  a true  continental  climate,  with  very  cold  winters 
and  intensely  hot  summers. 

Dr.  Jones  frilly  admitted  the  truth  of  much  which  had  been  said  by  the  speakers 
as  to  the  effects  of  crowding,  foul  emanations,  imperfect  feeding,  sour  milk,  putrid 
and  poisonous  milk,  inducing  this  disease,  and  he  fully  endorsed  the  rules  laid  down 
as  to  the  necessity  of  the  greatest  care  in  the  treatment  of  cholera  infantum.  He 
had  listened  with  great  interest  to  the  paper  of  his  friend — Dr.  Maxwell,  of  Florida 
— who,  as  far  as  his  information  extended,  was  the  original  inventor  of  the  laryngo- 
scope. He  also  knew  him  as  an  eminent  and  successful  practitioner  and  teacher  of 
medicine. 

Dr.  Thomas  Hebert,  of  New  Iberia,  La. — I have  seen  cholera  infantum  in 
Louisiana  during  J uly  and  August,  but  not  to  any  great  extent. 


CLINICAL  HISTORY  AND  TREATMENT  OF  MALARIAL  CONTINUED 
FEVER,  ESPECIALLY  AS  OBSERVED  IN  TEXAS,  AND  ITS 
DIFFERENTIATION  FROM  ENTERIC  FEVER. 

HISTOIRE  CLINIQUE  ET  TRAITEMENT  DE  LA  FIEVRE  PALUDEENNE  CONTINUE 
SPECIALEMENT  COMME  ELLE  EST  OBSERVEE  AU  TEXAS,  ET  SA 
DIFFERENCE  D’AVEC  LA  FIEVRE  TYPHOIDE. 

KLINISCHE  GESCHICHTE  UND  BEHANDLUNG  DES  CONTINUIRLICHEN  MALAR! AFIEBERS, 
MIT  SPECIELLER  HINSICHT  AUF  BEOBACHTUNGEN  IN  TEXAS,  UND  DIE 
DIFFERENTIALDIAGNOSE  ZWISCHEN  DEMSELBEN  UND 
DEM  ENTERISCHEN  FIEBER. 

BY  BLAIR  D.  TAYLOR,  M.  D. , 

Of  Columbus  Barracks,  Ohio. 

In  common  with  other  observers  in  the  South,  I can  devise  no  name  for  this  variety 
of  “continued  fever”  more  appropriate  than  the  one  given  in  the  title  of  this  paper. 
While  it  is  chiefly  of  malarial  origin,  it  is,  at  the  same  time,  partly  a fever  of  “acclima- 
tization,” and  is  undoubtedly  aggravated,  and  to  some  extent  caused,  by  the  intense 
and  long-continued  heat  prevailing  in  those  States  in  which  it  is  most  prevalent. 

It  is  never  seen  except  in  localities  subject  to  malarial  emanations,  and,  to  my 
knowledge,  is  not  found  north  of  the  thirty-sixth  parallel ; while  the  southern  portion 
of  Texas,  some  parts  of  Mississippi,  Louisiana  and  Arkansas  may  be  looked  upon  as  its 
natural  home 

It  is  regarded  by  some  as  identical  with  the  “ typlio-malarial  ” fever  of  Woodward  ; 
but  it  is  simply  adynamic  without  abdominal  symptoms,  and  seems  to  depend  for  its 
origin,  much  less  than  that  disease,  upon  over-crowding,  filth,  poor  food  or  other  unsani- 
tary conditions.  New  residents  are  oftenest  attacked,  many  of  them  being  in  military 
posts  of  unusual  cleanliness ; while  Mexicans,  existing  in  the  midst  of  dirt,  foul  water 
and  general  untidiness,  are  seldom  affected.  Many  physicians  not  familiar  with  this 
disease  will  often  pronounce  it  enteric  fever  upon  sight ; but,  as  I hope  to  show,  it  has 


542 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


well-marked  diagnostic  symptoms,  by  means  of  which  it  can  he  readily  distinguished 
from  that  affection. 

With  regard  to  my  opportunities  for  the  study  of  this  disease,  I will  state  that  I 
served  from  1881  to  1885,  two  years  at  Fort  Ringgold,  on  the  lower  Rio  Grande,  and 
the  same  length  of  time  at  Fort  Clark,  which  is  twenty-five  miles  from  the  river,  and 
about  one  hundred  and  thirty  miles  west  of  San  Antonio,  Texas.  During  this  period 
I had  sole  charge  of  numerous  cases,  and  saw  many  more  under  the  care  of  others.  At 
Fort  Ringgold  I experienced  two  attacks  in  my  own  person,  the  first  in  June,  1882, 
lasting  four  weeks,  and  the  second  in  January,  1883,  nearly  six. 

In  a paper  of  this  kind,  intended  to  embody  only  conclusions  and  opinions  derived 
from  personal  experience,  it  would  be  tiresome  to  recapitulate  verbatim  et  literatim 
records  of  the  numerous  temperature  charts,  and  clinical  histories  of  the  cases  pre- 
served ; and  I am  persuaded  that  an  account  of  the  average  symptoms  noticed  in  the 
majority  of  instances  would  better  convey  to  the  profession  my  own  knowledge  of  the 
subject,  and  better  enable  them  to  estimate  that  knowledge  at  its  true  value. 

Malarial  continued  fever  rarely  occurs  before  the  month  of  June  and  seldom  after 
the  month  of  November.  My  own  second  attack  and  that  of  one  of  my  family  took 
place  in  January ; but  I never  saw  a case  of  this  disease  in  either  February,  March, 
April  or  May.  The  latter  part  of  July,  the  months  of  August,  September  and  October 
cover  the  time  of  its  greatest  prevalence. 

The  average  temperature  in  the  shade  for  the  whole  of  this  period  collectively  will, 
at  Ringgold,  seldom  fall  short  of  75°  F.,  and  I have  seen  the  maximum  during  July 
reach  110°  F.  and  over  for  every  single  day  in  the  month. 

The  onset  of  this  disease  is  almost  typical  of  its  malarial  origin.  The  chill  is  sudden 
and  well-marked  in  the  majority  of  cases,  without  having  been  preceded  by  any  feeling 
of  malaise.  This  is  accompanied  and  followed  by  muscular  and  arthritic  pains,  head- 
ache, yawning,  stretching,  nausea,  and  often  vomiting,  with  a general  feeling  of  lassi- 
tude and  weariness.  The  temperature  at  once  rises  to  103°-104°  F.,  seldom  less. 

I have  frequently  seen  this  train  of  symptoms  followed  by  sweating  and  a subsidence 
of  the  temperature,  with  a complete  intermission,  and  on  the  next  day,  at  the  same 
hour,  a repetition  of  the  attack,  which  would  then  become  continuous.  The  tongue 
appears  flabby,  broad,  thick,  covered  with  a heavy  white  coating,  and  showing  the  marks 
of  the  teeth  around  its  edges.  This  is  what  I call  a malarial  tongue,  and  may  also  be 
found  in  remittent  and  intermittent  fevers. 

The  bowels  are  generally  constipated,  although  occasionally  diarrhoea  is  present, 
which  is  usually  due  to  some  preceding  error  of  diet  or  to  a large  dose  of  quinine.  As 
already  mentioned,  nausea  and  vomiting  of  green  or  yellow  bile  are  common  occurrences, 
frequently  accompanied  by  tenderness  over  the  liver,  spleen  or  stomach.  The  urine  is 
scanty  and  high  colored.  There  may  be  epistaxis  early  in  the  disease,  but  it  seldom 
occurs  before  the  end  of  the  first  week,  and  then  continues  at  intervals  during  the 
remainder  of  the  attack. 

The  pulse,  as  a rule,  is  in  the  beginning  full  but  soft,  and  rarely  exceeds  100-112 
per  minute  during  the  progress  of  the  disease.  I have  seen  it  reach  125  a few  times  in 
cases  ending  in  recovery,  but  this  is  uncommon. 

The  temperature  is  seldom  less  than  103°-104°  F.  at  the  outset.  I remember  one  case 
in  which  the  thermometer  never  registered  less  than  104°  at  any  time  during  the  twenty- 
four  hours  for  seven  days  ; nevertheless,  the  patient  regained  his  health.  As  a rule  the 
temperature  varies  from  2°-4°  F.  between  morning  and  evening,  the  morning  pyrexia 
being  the  lowest.  In  some  instances,  however,  this  rule  is  reversed.  There  is  not 
nearly  the  same  regularity  in  the  rise  and  fall  of  the  mercury  in  malarial  continued 
lever  as  in  its  enteric  rival ; and  this  is  not  only  true  as  to  the  daily  variation,  but 
also  from  week  to  week.  The  temperature  is  liable  to  make  sudden  and  erratic 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  543 

excursions,  up  or  down,  without  any  apparent  cause  and  without  ever  becoming 
normal. 

The  body  heat  and  pulse  do  not  seem  to  correspond  in  this  disease.  In  some  cases 
I have  seen  the  thermometer  over  105°  F.  and  the  pulse  under  100.  A peculiar  feature 
is  the  fact  that  for  some  days  after  convalescence  is  established  the  temperature  seems 
to  swing  hack  like  a pendulum,  just  in  proportion  to  its  former  excursion  in  the  opposite 
direction,  until  a minimum  of  97°,  96°,  and  even  95.6°  F.  is  reached.  This  may  seem 
an  extraordinary  statement,  but  these  extremely  low  temperatures  have  been  verified 
by  myself,  and  with  thermometers  corrected  either  at  the  Yale  or  Washington  observa- 
tories. Temperatures  below  96°  F.  I have  seen  iu  only  a few  instances,  but  97°  F.  or 
less  is  the  rule,  in  my  experience,  during  the  early  stages  of  recovery. 

I would  also  state,  in  this  connection,  that  the  thermometer  in  all  of  my  cases  was 
placed  under  the  tongue.  When  the  temperature  falls  to  the  normal  at  any  time,  the 
patient  may  be  regarded  as  having  very  nearly  reached  the  limit  of  his  illness.  From 
this  time  on  there  is  no  continued  fever,  but  intermittent,  the  thermometer  registering 
98.6°  F.  or  less  in  the  morning,  and  reaching  101°-102  in  the  evening.  This  condition, 
however,  only  lasts  a few  days  before  the  pyrexia  entirely  disappears. 

Headache,  as  mentioned  above,  is  always  present,  but  in  some  cases  it  is  a prominent 
symptom,  amounting  to  cerebral  congestion,  accompanied  by  delirium,  sleeplessness  and 
hallucinations. 

The  tongue  changes  its  appearance  after  the  second  or  third  week,  more  or  less, 
according  to  the  severity  of  the  attack,  becoming  dry,  brown,  and  cracked,  with  sordes 
on  the  lips  and  teeth  ; in  fact,  it  presents  a typhoid  appearance,  so  called,  but  which  can 
be  found  in  other  varieties  of  continued  fever  as  well,  and  also  in  dysentery.  This  state 
of  the  tongue,  however,  is  unaccompanied  by  an  eruption  or  abdominal  symptoms 
referable  to  the  right  iliac  region.  Tenderness  over  the  liver  or  spleen,  with  more  or 
less  enlargement  of  the  latter,  may  be  concomitants  of  the  condition  referred  to. 

Among  the  sequelae  of  this  fever  may  be  enumerated  great  muscular  and  mental 
weakness,  the  former  almost  amounting  to  paralysis,  while  the  latter  may  result  in 
temporary  mania,  though  oftenest  in  melancholia.  The  patient  previously  mentioned, 
whose  temperature  remained  so  high  for  a week,  was  affected  with  suicidal  mania  for 
ten  days  after  his  pyrexia  had  disappeared,  and  the  thermometer  registered  below  the 
normal.  Being  prevented  from  destroying  himself,  he  begged  me,  on  each  visit,  to  “cut 
his  head  off  with  a hatchet.” 

In  another  case,  occurring  at  Little  Rock,  Ark.,  the  soldier  had  to  be  discharged 
the  service  for  weakness  of  intellect,  melancholia  and  peculiar  eccentricities,  following 
an  attack  of  malarial  continued  fever  which  lasted  over  forty  days.  I have  no  doubt, 
however,  that  he  completely  recovered  within  eighteen  months  or  two  years. 

Differential  Diagnosis. — The  only  fever  of  a continued  type  with  which  the  disease 
under  consideration  might  be  confounded  is  enteric  fever.  I use  the  term  “enteric” 
instead  of  “typhoid,”  as  more  clearly  defining  the  natural  and  anatomical  lesions  of 
that  affection.  The  strongest  point  of  resemblance  between  the  two  diseases  is  found 
in  the  dry,  brown,  cracked  tongue  of  the  third  week  of  malarial  continued  fever.  This 
appearance  of  the  tongue,  however,  is  more  or  less  common  in  the  latter  stages  of  all 
continued  fevers  of  an  adynamic  type,  and  of  over  twenty  days’  duration.  Another  symp- 
tom in  which  an  agreement  may  be  discovered  is  the  cephalalgia  and  delirium;  but  the 
former  is,  in  my  experience,  most  severe  in  malarial  continued  fever,  while  the  latter 
is  seldom  ever  of  the  low,  muttering  character  so  often  found  in  enteric.  In  this  connec- 
tion, I may  mention  that  all  of  the  few  cases  of  enteric  fever  seen  by  me  in  Texas  died; 
generally  about  the  twenty-first  day,  and  of  perforation  and  peritonitis.  One  peculiar 
case,  and  the  only  one  occurring  at  Fort  Ringgold,  was  fatal  on  the  fourteenth  day.  The 
eruption  was  well  marked  on  the  head  (which  was  bald),  and  on  the  neck,  arms  and 


544 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


breast,  with  very  few  spots  on  the  abdomen.  In  this  case,  the  temperature  was  106.2°  F. 
just  before  death,  and  the  autopsy  revealed  extensive  ulceration  of  Peyer’s  glands,  as  far 
as  they  extended  in  the  commencement  of  the  ileum,  with  perforation,  hemorrhage  and 
peritonitis. 

With  the  appearance  of  the  tongue  late  in  the  continued  fever  of  malarial  origin, 
and  the  symptoms  referable  to  the  nervous  system,  the  resemblance  between  the  two 
diseases  ceases. 

The  points  of  difference  are  much  more  prominent.  In  the  first  place,  the  onset  of 
malarial  continued  fever  is  either  sudden,  the  chill  being  marked  and  immediately  fol- 
lowed by  a high  temperature,  or  it  is  preceded  by  one  or  more  attacks  of  quotidian  or 
tertian  intermittent.  In  enteric  fever  the  chilly  sensation  is,  as  a rule,  slightly  pro- 
nounced, and  the  initial  symptoms  may  be  prolonged  for  several  days  before  the  patient 
feels  it  necessary  to  take  to  his  bed.  In  my  experience,  the  temperature  in  enteric 
fever  seldom  rises  above  102°-102.5°  F.  until  the  end  of  the  first  week,  while  in  the 
malarial  affection  the  body  heat  rises  at  once  to  103°~104°  F.,  or  even  more.  The 
appearance  of  the  heavy  white  coating  on  the  broad,  thick  and  indented  tongue  is 
highly  characteristic  of  the  beginning  of  malarial  continued  fever,  while  my  own  obser- 
vation of  the  enteric  affection  has  generally  shown  a narrow,  pointed,  red  tongue,  with- 
out indentations  from  the  teeth,  and  with  a slight  fawn-colored  or  brownish  fur,  rather 
than  white. 

The  most  radical  difference,  however,  is  to  be  found  in  the  complete  absence  of  the 
typhoid  eruption,  and  of  all  those  abdominal  symptoms  so  characteristic  of  enteric  fever. 

In  malarial  continued  fever  there  is  seldom  diarrhoea — rather  constipation — no  tender- 
ness on  pressure  in  the  right  iliac  fossa,  no  tympanites,  no  gurgling,  and  no  rose-colored 
lenticular  spots,  disappearing  under  pressure,  and  after  death. 

In  nujarial  continued  fever  there  may  be  present  tenderness  over  the  liver,  spleen 
or  stomach,  but  not  elsewhere  in  the  abdominal  cavity.  Seventeen  years  ago  I was 
taught  by  Dr.  Alfred  L.  Loomis  that  there  could  be  no  case  of  typhoid  fever  without 
the  characteristic  eruption,  and  my  subsequent  experience  has  confirmed  this  state- 
ment. I believe  the  spots  can  always  be  found  between  the  seventh  and  twelfth  days, 
if  carefully  looked  for. 

The  erratic  behavior  of  the  temperature  in  the  Texas  fever  is  still  another  distin- 
guishing feature.  For  instance,  it  may  rise  to  its  maximum  in  the  first  week,  and  may 
fall  as  suddenly  below  100°  F.  in  the  second;  these  excursions,  however,  only  occupy  a 
few  hours.  Seldom  a whole  day  passes  with  the  thermometer  below  102°,  unless  the 
pyrexia  has  been  artificially  reduced,  i.  e. , until  convalescence  is  established.  Some- 
times the  thermometer  will  vary  less  than  one  degree  in  the  twenty-four  hours  for  days 
at  a time.  I have  known  it  to  remain  steadily  above  104°  F.,  and  not  over  105°  F., 
for  a whole  week. 

The  regular  daily  fall  and  rise  of  the  temperature  in  enteric  fever,  as  well  as  its 
steady  increment  from  week  to  week  to  the  maximum,  and  its  no  less  steady  decrease 
toward  recovery,  have  been  observed  so  often  as  to  be  considered  one  of  the  diagnostic 
features  of  this  disease. 

I have  not  dwelt  on  epistaxis  as  common  to  these  maladies,  as  it  also  occurs  in  other 
fevers  of  continued  type,  and  in  relapsing  fever.  There  is  no  special  character  of  the 
pulse  by  means  of  which  these  two  diseases  may  be  distinguished,  other  than  the  fact 
of  its  greater  rapidity  in  enteric  fever,  while  at  the  same  time  it  lacks  the  soft  fullness 
so  frequently  observed  in  the  malarial  affection. 

The  prognosis  is  favorable  with  proper  treatment,  much  more  so  than  the  high  tem- 
perature, brown,  dry,  cracked  tongue,  delirium,  duration  of  the  disease  and  general 
appearance  of  the  patient  would  lead  one  to  expect.  Of  the  numerous  cases  under  my 
immediate  charge  during  the  four  years  of  my  service  in  Texas,  only  one  died,  and  he 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


545 


was  treated  in  his  own  house,  where  there  were  no  conveniences  for  haths,  and  lie  was, 
moreover,  a new  comer  and  of  a very  delicate  constitution.  Of  the  cases  mentioned,  the 
average  duration  of  the  pyrexia  was  28  days  ; in  none  was  it  less  than  21,  and  in  only 
a few  over  42. 

Of  pathological  appearances  I can  say  little,  as  no  autopsy  was  permitted  in  my  own 
fatal  case,  and  I had  no  opportunity  of  witnessing  a post-mortem  in  those  of  others. 

The  patient  who  died  under  my  care  succumbed  on  the  twenty-eighth  day  of  the 
disease,  from  heart  failure,  and  according  to  my  observation,  the  tendency  to  death  is 
in  that  direction. 

Treatment. — When  I was  an  interne  of  Bellevue  Hospital,  1869  and  1870,  we  gave 
large  doses  of  quinine  to  every  patient  affected  with  malaria  in  any  form,  and  very 
properly,  too,  in  the  class  of  cases  seen  in  New  York,  which  were  either  of  the  inter- 
mittent or  remittent  type,  with  occasionally  a congestive  chill.  We  used  this  remedy 
antiperiodically,  antipyretically  and  heroically,  if  necessary.  In  consequence  of  this 
previous  experience  and  prejudice  in  favor  of  large  doses  of  quinine,  the  first  few  cases 
of  the  disease  in  question  were  treated  by  me  on  the  principle  that  if  thirty  or  forty  grains 
of  quinite  sulph.  did  not  break  up  this  malarial  continued  fever,  sixty  grains  would. 
I tried  it  and  failed , not  only  to  break  up  the  fever  and  reduce  the  temperature  to  any 
appreciable  extent,  but  succeeded  in  making  the  patient  so  deaf,  blind  and  wild  that 
nothing  could  quiet  him.  After  trying  this  remedy  on  several  patients,  I abandoned  it 
altogether  as  an  antipyretic,  and  used  it  only  as  an  antiperiodic  when  convalescence 
was  just  beginning  and  there  was  a complete  intermission.  I do  not  dispute  the  fact 
that  quinine  in  large  doses  will  reduce  the  temperature  from  — .5°-1.5°  F.,  but  it  does 
this,  in  this  disease,  at  the  expense  of  the  already  overstrained  and  oxidized  nervous  cen- 
tres, and  when  used  to  such  an  extent  is  liable  to  produce  permanent  deafness,  and 
more  or  less  injury  to  other  special  senses.  Another  strong  objection  to  its  use  is  the 
nauseating  and  disagreeable  effect  it  has  on  the  stomach,  rendering  the  administration 
of  nourishment  or  medicines  almost  impossible. 

I must  register,  also,  my  protest  against  the  early  use  of  stimulants  in  malarial  con- 
tinued fever.  They  seldom  become  necessary  before  the  third  week  of  this  affection,  and 
most  of  the  fatal  cases  I have  seen  and  heard  of  were  treated  in  the  beginning  of  the 
disease  with  large  doses  of  brandy  and  quinine. 

Some  of  the  best  surgeons  who  have  served  in  Texas  do  not  agree  with  me  in  the 
opinions  above  expressed;  others  do;  nevertheless,  lam  obliged  to  draw  my  own  deduc- 
tions from  observed  facts,  and  j udge  of  the  efficacy  of  treatment  by  its  results.  I have, 
moreover,  taken  great  interest  in  this  disease,  and  made  somewhat  of  a special  study  of 
it,  not  only  in  others,  hut  also  in  my  own  person. 

Having  entered  my  protest  against  the  quinine  and  brandy  treatment,  I will  now  for- 
mulate an  opinion  as  to  what  I consider  the  proper  management  of  this  disease.  The 
indications  for  treatment  appear  to  me  to  he  as  follows  : — 

1.  To  keep  the  secretions  and  excretions  free. 

2.  To  build  up  the  patient  with  proper  nourishment,  and  stimulants  when  required 
by  the  condition  of  the  pulse. 

6.  To  quiet  the  excited  brain  and  procure  refreshing  sleep. 

4.  And  above  all,  to  reduce  the  body  heat  and  keep  it  down,  as  far  as  practicable. 

To  meet  the  first  indication,  I have  used  as  a routine,  and  certainly  harmless  pre- 
scription, 10  rrL  each  of  syr.  rhei.  arom.,  liq.  animon.  acetat.  and  spts.  sctheris  nitrosi, 
administered,  diluted,  every  four  hours.  For  this  special  combination  I am  indebted 
to  Dr.  A.  Heger,  Lieutenant-Colonel  and  Surgeon,  U.  S.  Army,  then  stationed  at  Fort 
Clark,  Texas,  and  whose  four  years  of  experience  with  this  disease  had  independently 
led  him  to  adopt  very  nearly  the  same  views  as  myself. 

The  combination  above  mentioned  appears  to  me  to  benefit  by  its  gentle  stimulating 
Vol.IV— 35 


546 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


effect  upon  the  excretory  function  of  the  skin,  kidneys,  liver  and  intestinal  tract.  In 
the  beginning  of  the  disease,  when  the  constipation  was  a prominent  symptom,  I have 
often  derived  benefit  from  the  exhibition  of  six  grs.  each  of  calomel  and  mass,  hydrarg.,  ! 
in  the  pilular  form,  and  followed,  if  necessary,  in  six  hours  by  a Seidlitz  powder  or 
moderate  dose  of  magnes.  sulph.  I prefer,  however,  one  of  the  saline  cathartics,  as  a 
rule. 

During  the  further  progress  of  the  disease,  when  the  bowels  are  inactive,  I use  1 
either  an  enema  of  warm  water  and  soap  or  a laxative  pill  composed  of  podopliyllin,  1 
gr.  4;  extr.  colocynthi.  co.,  gr.  1 ; extr.  hyoscyami,  extr.  nucis  vomicae  and  extr.  ta-  i 
raxaci,  aa  gr.  j-.  Strong  purgatives  are  to  be  avoided. 

The  second  indication  may  be  best  met  by  such  easily  digestible  nourishment 
as  suits  the  patient’s  stomach  and  is  especially  desired  by  him. 

In  my  experience,  milk  has  served  the  purpose  better  than  anything  else.  I have 
very  little  faith  in  the  various  forms  of  “meat  juice”  and  “beef  extracts,”  except 
possibly  as  stimulants.  As  to  the  latter,  they  should  only  be  used  when  the  pulse  first 
fails  in  strength.  I generally  begin  with  sherry  and  egg  in  small  quantities,  frequently 
repeated,  and  progress  to  whisky  or  brandy,  in  the  form  of  milk  punch,  as  the  case 
appears  more  serious.  When  the  heart’s  action  becomes  excessively  weak,  I have  found 
much  benefit  from  the  administration  of  10  n\,  doses  of  tinct.  digitalis,  repeated  as 
required. 

The  nervous  excitement  of  the  third  indication  can  be  best  controlled  by  15  to  20 
grs.  each  of  chloral  hydrat.  and  potass,  bromide,  given  at  bedtime.  In  some  few 
instances,  however,  this  prescription  seems  to  aggravate  the  restlessness  and  delirium 
In  such  cases  4 gr.  morph,  sulph.,  administered  hypodermically,  will  generally  produce 
quiet  and  sleep. 

The  above  statement  was  illustrated  in  my  own  person,  the  bromide  and  chloral 
acting  well  in  the  first  attack,  while  in  the  second  morphia  had  to  be  substituted.  Do 
not  understand'  me  to  recommend  the  daily  use  of  these  remedies  ; they  are  only 
required  occasionally. 

With  me,  nothing  has  fulfilled  the  fourth  indication  so  well  as  cool  baths  and  cool 
sponging. 

I had  the  temperature  of  each  patient  taken  every  two  hours,  from  6 A.  M until  10 
p.m.,  and  when  the  thermometer  indicated  103°  F.  or  more,  he  was  at  once- placed  in  a 
bath-tub  of  water  kept  constantly  standing  by  his  bed.  These  tubs  were  long  enough 
to  admit  of  the  immersion  of  the  whole  body  except  the  head,  and  the  latter  was 
drenched  with  a sponge  during  the  entire  time  of  the  bath. 

The  patient  was  allowed  to  remain  in  the  water  until  he  complained  of  feeling 
chilly,  when  he  was  immediately  removed.  The  times  of  immersion  varied  from  five 
to  fifteen  minutes — the  average  being  about  eight  minutes. 

There  was  no  ice  at  Fort  Ringgold,  and  the  lowest  temperature  obtainable  for  water 
during  the  fever  season  was  74°  F.  I preferred  the  bath,  however,  at  80°-84°  F.,  as 
the  shock  of  colder  water  was  too  great  for  feeble  patients.  There  is  not  the  slightest 
danger  in  this  mode  of  treatment  if  the  rule  given  above  is  observed,  i.  e. , to  take  the  ; 
patient  out  of  the  bath  as  soon  as  he  complains  of  feeling  chilly;  reaction  will  invari- 
ably occur  under  these  circumstances.  When  the  temperature  is  over  100°  F.  and  not 
more  than  103°  F.  I use  sponging  instead  of  the  bath. 

With  regard  to  the  antipyretic  effect  of  this  treatment,  I will  state  that  in  the  fewest  j 
number  of  instances  has  it  failed,  in  my  hands,  to  reduce  the  temperature  from  2°-4°  F.  , 
Often  have  I seen  the  thermometer  fall  from  104.5°-9f).6°  F.  Frequently,  in  severe  ; 
cases,  five  or  six  baths  a day  are  required,  and  the  amount  of  difficulty  experienced  in  5 
reducing  the  temperature  may  be  taken  as  a measure  of  the  severity  of  the  attack. 

It  is  true  that  this  lowering  of  the  body  heat  is  not  permanent,  but  it  frequently  I 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  547 


lasts  as  much  as  an  hour,  and  these  hours  added  up  for  the  whole  period  of  the  disease 
correspond  to  a long  season  of  rest  from  oxidation  aud  waste  of  the  tissues,  which  is  of 
incalculable  benefit  to  the  patient. 

An  additional  advantage  of  the  water  treatment  is  the  perfect  cleanliness  of  the 
skin  thus  secured,  while  the  pores  are  kept  open  and  transpiration  encouraged.  More- 
over, the  bath  calms  aud  quiets  the  brain,  and  I have  often  seen  patients  go  off  into 
a natural  sleep  afterward  without  any  necessity  for  anodynes  or  soporifics.  I must 
mention,  before  concluding,  that  in  some  cases  the  symptoms  referable  to  the  brain 
and  nervous  system  are  replaced  by  excessive  irritability  of  the  stomach,  rendering 
it  very  difficult  to  administer  either  food  or  medicine.  In  the  case  of  an  officer  at 
Fort  Clark,  he  could  retain  nothing  but  very  small  quantities  of  iced  champagne,  and 
occasionally  a little  cold  milk.  I succeeded,  however,  in  subduing  this  annoying  state 
of  affairs  by  drawing  a blister,  about  au  inch  and  a half  in  diameter,  over  the  epigas- 
trium, and  keeping  it  open  for  several  days. 

During  convalescence  I have  found  ferri  et  quinise  citras,  in  five-grain  doses  three 
times  a day,  the  most  suitable  and  beneficial  tonic.  Quinine  alone  I seldom  give,  except 
at  the  termination  of  the  continued  pyrexia,  when  there  is  a complete  intermission  in 
the  morning.  I may  also  state  that  I have  tried  quinia  in  small  doses — 4 grs.  ter  die 
— during  the  whole  disease,  but  abandoned  it,  because  I could  not  observe  that  the 
malady  was  at  all  influenced  by  its  exhibition,  except  for  the  worse,  as  far  as  the 
brain  and  stomach  were  concerned. 

In  presenting  these  views  of  “malarial  continued  fever”  and  its  treatment,  no 
claim  to  originality  is  made,  but  I have  simply  recorded  clinical  facts  as  they  appeared 
to  me,  and  the  natural  deductions  therefrom  as  to  the  nature  of  the  disease  and  its  man- 
agement. 

It  may  seem  strange  to  speak  of  a malarial  fever  and  then  deny  the  efficacy  of  qui- 
nine in  its  treatment.  This  opinion,  however,  applies  only  to  its  antipyretic  and  not 
at  all  to  its  antiperiodic  action.  According  to  my  observation,  this  remedy  is  more 
potent,  even  in  remittent  or  intermittent  fevers,  if  administered  when  the  temperature 
is  at  or  near  the  normal  and  the  excretions  free. 

In  conclusion,  I must  apologize  for  having  presented  nothing  new  or  strange,  but  as 
each  little  drop  adds  something  to  the  ocean,  so  the  truly  recorded  experiences  of  us  all 
are  required  to  complete  the  mighty  structure  of  our  noble  science. 


DISCUSSION. 

Dr.  Thomas  Hebert,  of  New  Iberia,  Louisiana,  said  that  his  experience  in 
Louisiana  coincided,  with  reference  to  the  clinical  history  and  treatment  of  mala- 
rial continued  fever,  with  that  observed  by  Dr.  Blair  D.  Taylor,  in  Texas. 


548 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ON  THE  SANITARY  INSPECTION  OF  PASSENGER  COACHES. 

SUR  L’INSPECTION  SANITAIRE  DES  VOITURES  DE  VOYAGEURS. 

UBER  SANITATSAUFSICHT  UBER  EISENBAHN WAGGONS. 

BY  R.  HARVEY  REED,  M.D., 

Of  Mansfield,  Ohio. 

In  the  collection  of  material  for  the  preparation  of  this  report  it  has  been  our  aim 
to  he  as  careful  and  thorough  as  circumstances  would  permit;  we  have  also  tried  to 
procure  all  the  facts  possible  pertaining  to  sanitary  matters  connected  with  passenger 
coaches,  and,  so  far  as  possible,  have  tabulated  them  in  a convenient  form  for  reference. 
We  have  also  tried  to  collect  enough  of  each  to  enable  us  to  arrive  at  general  conclu- 
sions, based  on  the  facts  collected. 

For  the  collection  of  these  facts  we  have  chosen  four  fairly  typical  American  rail- 
roads— roads  that  we  thought  would  unquestionably  represent  the  general  condition  of 
first-class  railroads  throughout  our  land— on  each  of  which  we  inspected  the  coaches  of 
only  first-class  passenger  trains,  all  of  which  were  subjected  to  the  same  scrutiny 
throughout. 

For  aiding  me  in  this  task  I am  indebted  to  Mr.  G.  M.  Beach,  Manager  of  the 
Cleveland,  Columbus,  Cincinnati  and  Indianapolis  Railroad;  Mr.  Wm.  Baldwin,  Man- 
ager of  the  Pittsburgh,  Cincinnati  and  St.  Louis  Railroad  (known  as  the  Pan  Handle), 
and  the  Pittsburgh,  Fort  Wayne  and  Chicago  Railroad  (known  as  the  Fort  Waynej,  ! 
and  Mr.  W.  W.  Peabody,  Manager  of  the  Baltimore  and  Ohio  Railroad,  each  of  whom 
furnished  me  valuable  assistance  in  the  way  of  transportation  and  the  collection  of 
facts  pertaining  to  our  investigations. 

I am  also  indebted  to  Prof.  C.  C.  Howard,  chemist  for  the  Starling  Medical  College, 
Columbus,  Ohio,  for  the  chemical  analysis  of  the  air  and  water,  and  his  report  of  the 
same,  found  herewith;  and  to  Dr.  J.  Harvey  Craig,  of  Mansfield,  Ohio,  for  necessary 
and  needed  assistance  in  the  collection  of  facts. 

Different  times  of  the  year,  with  their  corresponding  changes  of  weather,  were  chosen, 
a.s  well  as  roads  running  in  different  cardinal  directions  and  under  different  kinds  of 
management,  and  representing  different  styles  of  coaches  and  various  kinds  of  car 
furniture,  such  as  stoves,  heaters,  washstands,  water  tanks,  urinals,  etc.,  in  order  that 
our  report  might  be  as  complete  and  practical  as  possible,  and  our  deductions  based  on 
as  many  general  facts  as  circumstances  would  admit. 

TEMPERATURE. 

In  taking  the  temperature,  we  used  tested  thermometers,  of  Fahr.  scale,  and  first . j 
ascertained  the  condition  of  the  atmosphere  outside  the  car,  the  character  of  the  weather, 
direction  of  the  wind,  and  general  trend  of  the  train. 

Six  thermometers  were  used  in  each  car,  which  were  numbered  from  one  to  six,  _■ 
always  commencing  with  the  right  front  side  of  the  car,  and  counting  around  the  coach 
and  ending  with  the  sixth,  at  the  left  front  end  of  the  same,  thus  placing  two  ther-  I 
mometers  at  each  end  and  two  in  the  middle  of  each  car  (see  Fig.  1),  which  were  hung 
at  the  sides  of  the  car  as  near  the  level  of  the  heads  of  the  passengers  while  sitting  iu 
their  seats  as  was  practical,  and  always  placing  the  thermometers  in  the  same  relative 
position  in  each  car. 

The  temperature  was  then  noted  carefully  while  the  train  was  in  full  motion,  at 
intervals  of  from  twenty  minutes  to  half  an  hour,  and  in  a few  instances  as  much  as  au 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  549 


hour  apart,  and  also  taken  while  standing  at  different  stations,  usualty  making  the 
observations  immediately  before  the  train  left  the  depot ; and,  finally,  the  thermometers 
were  placed  on  the  floor  in  the  same  relative  positions  and  the  temperature  again  care- 
fully noted. 

Fig.  l. 


Average. 

4° 


The  general  results  of  these  observations  will  be  seen  by  the  following  tables  : — 

Table  No.  1. — Greatest,  least  and  average  difference  of  temperature  observed  between 
the  inside  and  outside  of  coaches  while  running,  during  the  winter  season— 

Greatest.  Least.  Average. 

80°  37°  54° 

The  same  observations  made  in  summer  showed — 

Greatest.  Least. 

7°  0° 

Table  No.  2. — Greatest,  least  and  average  difference  observed  between  the  extremes 
of  temperature  in  coaches  while  running,  during  the  winter  season — 

Greatest.  Least.  Average. 

27°  0°  7j° 

The  same  observations  made  in  summer  showed — 

Greatest.  Least.  Average. 

3°  0°  2° 

Table  No.  3. — Greatest,  least  and  average  difference  observed  between  extremes  of 
temperature  in  coaches  while  standing,  during  the  winter  season— 

Greatest.  Least.  Average. 

27°  1°  7° 

The  same  observations  made  in  summer  showed— 

Greatest.  Least.  Average. 

4°  2°  2j° 

Table  No.  4- — Greatest,  least  and  average  difference  observed  between  extremes  of 
temperature  in  coaches  running  and  standing,  during  the  winter  season — 

Greatest.  Least.  Average. 

29°  5°  13f° 

The  same  observations  made  in  summer  showed — 

Greatest.  Least.  Average. 

4°  3°  3J° 

Table  No.  5. — Greatest,  least  and  average  difference  observed  between  the  tempera- 
ture at  the  bottom  of  cars  and  the  level  of  the  head,  while  sitting  in  a running  car,  at 
full  speed,  during  the  winter  season — 

Greatest.  Least.  Average. 

30°  12°  18° 


550 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  same  observations  made  in  summer  showed  no  appreciable  difference,  as  might 
be  expected. 

By  reference  to  temperature  chart  No.  1,  you  will  find  that  the  greatest  difference  of 
temperature  between  the  outside  and  inside  of  a car  occurred  in  a smoking  car,  on 
December  16th,  1886,  with  the  mercury  at  4°  above  zero,  and  the  least  difference  occurred 
on  both  a smoker  and  sleeper,  of  the  same  date,  March  28th,  1887,  with  the  mercury 
outside  at  27°  and  30°  respectively. 

It  will  also  be  observed  that  the  greatest  difference  between  the  extremes  of  tempera- 
ture on  a car  while  running  occurred  on  a sleeper,  March  28th,  1887,  -with  the  mercury 
outside  at  27°  above  zero,  and  the  least  difference  between  the  extremes  of  temperature 
of  a car  while  running  was  on  a smoker,  on  December  29th,  1886,  with  the  mercury 
outside  at  22°  above  zero. 

The  greatest  difference  of  temperature  while  standing  occurred  on  a sleeper,  March 
28th,  1887,  with  the  mercury  outside  at  27°  above  zero,  while  the  least  difference  of 
temperature  while  standing  occurred  on  a sleeper,  December  29th,  1886,  with  the 
mercury  outside  at  16°  above  zero. 

Again  referring  to  chart  No.  1,  it  will  be  observed  that  the  greatest  difference  between 
extremes  of  temperatures  on  a coach  running  and  standing  was  on  a sleeper,  March  28th, 
1887,  with  the  mercury  at  27°  above  zero,  and  the  least  difference  occurred  on  a sleeper, 
December  16th,  1886,  with  the  mercury  outside  at  4°  above  zero,  the  coldest  day  we 
were  out  making  these  inspections. 

The  greatest  difference  found  between  the  temperature  at  the  bottom  of  a car  and 
tlijj  level  of  the  head,  occurred  on  a sleeper,  March  29th,  1887,  with  the  mercury  at 
12°  above  zero;  and  the  least  difference  was  on  a ladies’  coach,  two  of  which  registered 
the  same,  the  one  December  29th,  1886,  with  the  mercury  at  18°  above  zero,  and  the 
other  on  March  29th,  1887,  with  the  mercury  outside  at  12°  above  zero. 

HEATING. 

Again,  by  referring  to  chart  No  1,  it  will  be  seen  that  6}  per  cent,  of  the  cars  were 
heated  by  stoves  ; 36 J per  cent,  by  hotair;  and  56$  per  cent,  by  hot  water,  in  the  form 
of  the  Baker  heater. 

In  all  our  examinations,  only  two  cars  were  heated  by  common  stoves,  and  one  of 
those  was  found  in  summer,  which  was  useless  for  our  purpose  in  this  direction. 

In  the  one  found  in  use  in  the  winter,  it  will  be  observed  that  the  temperature  out- 
side the  car  was  10°  above  zero,  and  that  the  difference  between  the  extremes  of  tem- 
perature in  the  car  while  running  was  from  5°  to  6°,  and  the  same  while  standing, 
while  the  greatest  difference  of  temperature  on  the  same  car,  between  running  and 
standing,  was  8°,  while  that  between  the  bottom  of  the  car  and  head  was  17°. 

In  cars  heated  by  hot  air,  the  difference  between  extremes  of  temperature  while 
running,  was  from  2°  to  14°  with  the  mercury  outside  at  30°  and  15°  respectively. 

The  extremes  of  temperature  between  cars  heated  by  hot  air,  while  running  and 
standing,  was  from  8°  with  the  thermometer  outside  at  30°  above  zero  in  one  instance, 
and  15°  above  zero  in  another,  to  18°  with  the  mercury  outside  at  4°  at  one  time,  and 
15°  above  zero  at  another. 

In  cars  heated  by  hot  water,  there  was  found  a difference  of  temperature  while  run- 
ning, varying  from  0°  to  27°  with  the  mercury  outside  at  22°  and  27°,  respectively,  above 
zero,  and  a difference  of  temperature  between  running  and  standing,  varying  from  5° 
to  29°,  with  the  mercury  outside  at  4°  and  27°  respectively,  above  zero,  while  the  differ- 
ence between  extremes  standing  varied  from  1°  to  27°,  with  the  mercury  outside  at  16° 
and  27°,  respectively,  above  zero. 

By  the  same  methods  of  heating  a variation  of  temperature  between  the  bottom  of 
the  car  and  level  of  the  head  while  sitting  was  found,  varying  from  12°  with  the  mer- 


SECTION  XV PUBLIC  AND  INTERNATIONAL  HYGIENE.  551 

cnry  outside  at  18°  above  in  oue  instance  and  12°  above  in  another,  to  30°,  with 
the  mercury  outside  at  12°  above  zero. 

VENTILATION. 

We  found  43J  per  cent,  of  the  cars  ventilated  with  the  “ drop-sash  ” ventilators  (see 
Fig.  2);  23J  per  cent,  with  “registers”;  13£  per  cent,  with  “side-sash”;  63  percent, 
with  “ transoms  ”;  and  131  per  cent,  without  any  ventilators  at  all. 

By  “drop-sash  ” ventilators  we  mean  where  the  little  sash  at  the  top  of  the  car  is 
attached  below  by  hinges,  and  so  arranged  as  to  drop  inward  and  downward  when  it  is 
desired  to  ventilate  the  car  (Fig.  2,  a) ; and  by  a “side-sash  ” ventilator  we  mean  where 


Fig.  2. 


the  sash  at  the  top  of  the  car  are  hung  on  hinges  at  their  ends,  and  so  arranged  as  to 
open  outward  and  backward  when  it  is  desired  to  ventilate  the  car  (see  Fig.  2,  b). 

By  “ registers  ” we  mean  that  method  of  ventilation  by  which  the  air  is  allowed  to 
escape  near  the  top  of  the  car  by  means  of  a valvular  arrangement  on  each  side  of  the 
car,  which  can  be  opened  or  closed  at  will  (see  Fig.  3,  c). 

Ventilation  by  transoms  is  where  an  opening  is  usually  made  in  each  end  of  the  car, 
and  generally  a short  distance  above  the  door,  and  is  so  arranged  as  to  be  opened  or 
closed  by  means  of  a sash  or  wooden  arrangement,  capable  of  being  swung  on  its  centre 
at  will  (see  Fig  2,  c). 

By  “ pipe  ” ventilators  we  mean  simply  a pipe  running  through  the  roof  of  the  car 


Fig.  3. 


fx 

At 

* 

A 

Diagram  of  different  car  ventilators,  a,  common  pipe  ventilator;  b,  pipe  ventilator  with  fuunel  shaped 

top;  c,  common  register. 


from  the  inside,  and  ending  either  with  a simple  cover  or  funnel-shaped  arrangement 
on  its  top,  and  was  usually  found  in  the  toilets  and  water  closets  (see  Fig.  3,  a and  b.) 
The  circulation  of  air  through  the  car  was  tested  by  means  of  a wax  candle,  so  arranged 
as  to  protect  the  flame  from  all  draughts,  excepting  the  one  to  be  tested. 

The  cars  were  all  examined  just  as  found,  and  the  tests  made  when  the  car  was  run- 
ning at  or  near  the  schedule  speed  of  the  train. 

Each  window  was  tested  separately,  and  the  direction  of  the  currents  of  air  carefully 
noted  and  mapped  down  on  a blank  diagram,  prepared  for  that  purpose  (see  Fig.  4,  a), 
on  which  was  also  kept  the  date,  No.  of  car,  kind  of  car,  etc.,  which  corresponded 
with  the  record  kept  on  other  blanks,  prepared  for  that  purpose,  on  which  the  temper- 


552 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ature,  direction  of  'wind,  kind  of  heating  apparatus  and  other  general  facts  were 
recorded. 

After  testing  the  windows  for  draughts,  the  openings  at  the  top  of  the  cars,  of  what- 
ever character,  were  carefully  tested,  and  the  direction  of  the  currents  of  air  again  noted 
and  mapped  down  on  suitable  blanks.  (See  Fig.  4,  b.)  In  the  same  manner  the  ven- 
tilators of  each  of  the  toilets,  water  closets  and  urinals  were  in  turn  examined. 


Fig.  4. 


Almost  the  universal  result  of  these  investigations  showed  that  in  the  winter 
season,  when  the  cars  were  heated  artificially,  a constant  draught  of  cold  air  came 
in  around  the  windows,  notwithstanding  they  were  closed  and  many  of  them  double. 
(Fig.  6.)  These  currents  first  dropped  downward  toward  the  centre  of  the  car,  then 
arose  and  passed  out  at  the  ventilators  at  the  top  of  the  car.  They  were,  of  course, 

Fig.  5. 


A diagram  of  the  upper  part  of  a ear,  showing  the  circulation  of  the  air  while  running,  in  winter.  b,b, 
cold  air  entering  the  car  at  front,  transom;  c,  c,  hot.  and  foul  air  escapiug  at  top  of  car  through  the 
open  ventilators  at  the  side  and  transom  at  rear  end. 


more  or  less  modified  by  the  force  and  direction  of  the  air  outside  the  coaches,  also  by 
the  number  and  location  of  open  windows,  or  transoms,  and  ventilators.  (See  Fig.  5.) 
In  those  cars  in  which  hot-air  heaters  were  used,  and  which,  as  a rule,  are  usually  placed 
at  each  end  of  the  car,  with  a hot-air  conduit  running  along  each  outer  side  and  bottom 
of  the  car,  there  was  found  to  be  a great  uncertainty  in  the  supply  of  warm,  fresh  air. 


* 

SECTION  NV — PUBLIC  AND  INTERNATIONAL  HYGIENlt.  553 

As  a rule,  they  were  found  to  have  a good  draught  from  the  registers  of  those  con- 
duits (which  are  usually  placed  at  the  bottom  of  the  car,  opposite  each  seat)  which 
came  from  the  heater  at  the  front  eud  of  the  car,  while  from  those  coming  from  the  heater 
at-  the  rear  end  of  the  car,  there  was  usually  little  or  uo  draught. 

Iu  those  coming  from  the  heater  at  the  front  end  of  the  car,  the  draught  was  often 
so  strong,  and  the  air  so  hot,  as  to  necessitate  the  closing  of  the  register  by  the  party 
sitting  next  to  it,  while  his  neighbor  on  the  opposite  side  of  the  car  was  as  much  too 
cold  as  he  was  too  hot. 

' In  cars  heated  by  hot  water,  which  usually  consisted  in  a heating  apparatus  placed 
at  one  or  the  other  end  of  the  car,  with  an  arrangement  for  heating  salt  water  very  hot, 
usually  by  the  means  of  a coil  of  pipe,  which  was  continued  from  the  heater  around 
the  entire  car,  running  back  and  forth  under  each  seat,  as  it  encircled  the  car,  and  dually 
connecting  with  the  other  eud  of  the  coil  at  the  heater. 

By  this  ingenious  arrangement  a constant  current  of  hot  water  was  intended  to  be 
kept  circling  around  the  car,  which,  as  fast  as  it  became  cool,  would  return  to  the  heater, 
and  be  reheated  agaiu. 

Under  many  circumstances  these  were  found  inadequate  to  properly  heat  the  coaches 
in  cold  weather,  and  failed  to  keep  up  an  even  temperature  even  when  pushed  to  their 
utmost,  which,  in  turn,  would  modify  the  currents  of  air  throughout  the  car,  and  often 
necessitated  the  closing  of  the  ventilators  in  order  to  keep  the  passengers  comfortably 
warm,  and  were  utterly  useless  so  far  as  ventilating  the  car  was  concerned. 


Fig.  6. 


A diagram  showing  the  entrance  of  air  at  the  closed  windows  of  a running  car  in  winter,  a,  a,  Cold  air 

entering  the  car  at  the  windows. 

In  those  cars  provided  with  registers  at  the  top,  the  ventilation  was  found  very 
defective;  in  fact,  there  were  but  few  of  these  registers  in  which  there  was  the  faintest 
draught  perceptible  passing  either  out  or  in. 

Occasionally  one  would  have  a feeble  draught  out,  which  always  seemed  to  be  of  a 
spasmodic  character. 

The  same  may  be  said  of  the  pipe  ventilators,  excepting  in  those  with  a funnel- 
shaped  top,  which,  by  being  constructed  so  that  the  draught  made  by  the  moving  train 
would  always  throw  the  large  end  of  the  funnel  backward,  producing,  occasionally,  a 
slight  draught  from  the  inside  of  the  car  out. 

In  the  little  inch  and  a half  to  two-inch  pipes  intended  as  ventilators  for  the  hop- 
pers and  urinals,  there  was  little  or  no  draught  found  at  all. 

The  cars  in  which  the  best  circulation  of  air  was  found,  everything  else  considered, 
were  those  provided  with  the  side-sash  ventilators,  and  hot-air  heaters;  in  all  of  the 
former  there  was  found  to'  be  quite  a remarkable  regularity  iu  the  draught,  which  was 
always  found  outward,  except  when  changed  by  a strong  outside  current,  which  was 
seldom  the  case. 

In  those  ventilated  with  the  drop-sash  the  circulation  of  air  was  fair,  but  they  were 
susceptible  to  the  impressions  from  the  outside  air,  which  changed  the  currents  back 
and  forth  accordingly. 


554 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


In  the  summer  time,  when  there  was  no  fire  in  the  cars  and  nearly  all  the  windows 
open,  there  was  found  to  be  an  inward  draught  at  the  rear  side  of  each  window,  with 
an  outward  draught  at  the  front  side  of  the  same  ; while  in  the  same  cars  ventilated 
with  registers  there  was  a constant  outward  current  through  them;  in  the  cars,  how- 
ever, provided  with  drop-sash  ventilators,  there  was  almost  a constant  inward  draught 


Fig.  7. 


oo on 

Diagram  showing  the  general  circulation  of  air  through  a running  coach  in  winter. 


through  the  ventilators  and  a more  constant  outward  draught  through  the  open 
windows. 

In  the  accompanying  diagram  (see  Fig.  7),  I have  endeavored  to  show,  as  near  as 
possible,  the  prevailing  direction  of  the  air  currents  in  and  out  of  a majority  of  the 
cars  I have  inspected. 

LIGHTING. 

In  not  a single  instance  did  we  find  candles  used  for  lighting  the  coaches;  lamps 
being  used  entirely;  gas  having  also  been  abandoned  by  the  roads  that  used  it  a few 
years  ago. 

The  number  of  lamps  used  for  lighting  the  coaches  varied  from  four  to  twenty-seven 
in  a single  car. 

AIR  AND  WATER. 

For  the  following  report  of  the  chemical  analysis  of  the  air  in  the  coaches,  and  the 
drinking  water  used  by  the  different  roads  inspected,  I am  indebted  to  Prof.  C.  C.  t 
Howard,  of  Columbus,  Ohio,  who  accompanied  me  in  these  inspections,  and  made  all 
his  observations  on  the  running  train.  (See  Tables  No.  6 and  7. ) 

In  addition  to  Prof.  Howard’s  reports  of  the  air  and  water  analysis,  made  at  the  .. 
author’s  request,  he  adds  the  following  : — 

“The  apparatus  used  in  the  determination  of  the  carbon  dioxide  was  essentially 
that  proposed  by  Pettenkofer.  A glass  bottle  containing  3828  cubic  centimetres  was  t: 
filled  with  the  air  under  examination,  by  filling  it  with  water  and  removing  the  water 
with  a syphon.  50  cc.  of  barium  hydroxide  colored  with  phenol-plithalein  were  added 
and  shaken  with  the  contained  air  until  absorption  of  the  carbon  dioxide  was  complete,  ( 
and  this  titred  to  exact  discharge  of  color  with  a standard  solution  of  oxalic  acid,  ol  . 
which  1 cc.  is  equivalent  to  1 milligramme  of  carbon  dioxide. 

“ The  relation  between  the  strength  of  the  barium  hydroxide  and  oxalic  acid  solu-  ' 
tion  had  been  accurately  determined. 

“The  temperature  of  the  air  under  examination  and  the  barometric  pressure  were 
taken  and  the  volume  of  air  reduced  to  normal  conditions  of  temperature  and  pressure 
(0°  C.  and  760  mm.). 

“ From  the  diminished  alkalinity  of  the  barium  hydroxide  the  weight  of  the  carbon 
dioxide  present  was  calculated,  and  this  expressed  in  parts  per  10,000. 

‘ ' The  fact  that  the  apparatus  was  to  be  used  on  a ruuui  ug  train  required  that  it 
should  be  of  the  simplest  form. 

“ Comparative  tests  were  made  by  the  aid  of  the  apparatus  described  by  Van  NLiys,  | 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE, 


555 


TABLE  NO.  6. 

DETERMINATION  OF  CARBON  DIOXIDE  IN  AIR  OF  PASSENGER  COACHES  ON  THE 
FOLLOWING  RAILROADS  AND  CARS.  RATE  PER  10,000. 


Date. 

4 

No, 

R.  R. 

No.  of  Car. 

Condition. 

No.  of 
Passengers. 

Carbon  Dioxide. 
Parts  per  10,000.  j 

Dec.  29,  1886. 

1 

C.  C.  C.  & I. 

Smoker,  153. 

Front. 

8 

7.34 

ii  u 

2 

tt  t i 

Smoker,  153. 

Middle. 

8 

7.62 

ct  ct 

3 

tt  tt 

Coach,  356. 

Front. 

32 

14.26 

Ct  it 

4 

tt  ft 

Coach,  356. 

Middle. 

29 

13.68 

ti  l. 

5 

tt  tt 

Coach, 356. 

Rear. 

27 

11  53 

u a 

6 

tt  it 

Sleeper,  40, 

Front. 

11 

8.52 

7 

tt  It 

Sleeper,  40. 

Middle. 

11 

8.84 

8 

tt  It 

Sleeper,  40. 

Rear. 

11 

8.92 

9 

ft  tt 

Coach,  356. 

57 

18.33 

it  i< 

10 

It  tt 

Smoker,  153. 

23 

10.97 

March  28,  1887. 

11 

Pan  Handle. 

Smoker,  51. 

14 

5.60 

it  Cl 

12 

tt  it 

Coach,  36, 

18 

5.45 

a a 

13 

• t tt 

Coach,  36. 

25 

8.39 

tc  it 

14 

tt  tt 

Sleeper,  406. 

14 

11  36 

15 

tt  if 

Sleeper,  319. 

12 

13.35 

16 

tt  tt 

Coach,  36. 

22 

6.37 

u it 

17 

it  tt 

Smoker,  153. 

15 

8.73 

18 

tt  tt 

Coach.  36. 

Closed  for  35  minutes. 

23 

10.78 

ii  t 

19 

ft  tt 

Coach,  36. 

Doors  opened  2 minutes. 

21 

4.22 

March  29,  18S7. 

20 

Ft.  Wayne. 

Sleeper,  “ Metis.” 

10 

10.54 

it  it 

21 

a ct 

Smoker.  38. 

6 

6.81 

ii  ii 

2! 

ti  tt 

Coach,  16. 

24 

7.64 

ic  a 

23 

cc  it 

Coach,  26. 

23 

9.93 

it  ct 

24 

ct  ti 

Sleeper,  383. 

30 

12.28 

ct  tt 

25 

Smoker,  38. 

14 

6.13 

July  20,  1887. 

it  a 

26 

B.  AO. 

Smoker,  457. 

7 

4.87 

27 

ti  it 

Coach,  453. 

11 

4.41 

ii  a 

28 

it  it 

Coach,  469. 

15 

4.66 

it  a 

29 

it  If 

Sleeper,  505. 

12 

4.26 

30 

it  tt 

Coach,  457. 

29 

4.42 

it  ii 

31 

ii  it 

Coach, 431. 

24 

4.90 

it  cc 

32 

it  il 

Coach,  350. 

... 

17 

4.48 

TABLE  NO.  7. 

CHEMICAL  EXAMINATION  OF  WATER  (WITH  ICE)  FURNISHED  FROM  THE  FOLLOW- 
ING RAILROADS,  CARS  AND  PLACES.  RATE  PER  100,000. 


Date. 

No. 

R.  R. 

No.  of  Car. 

Source. 

Oxygen 

Required. 

Free 

Ammonia. 

Albuminoid 

Ammonia. 

Nitrous  Acid. 

Chlorine. 

Total  Solids. 

Dec.  29,  1886. 

1 

C.  C.  C.  & I. 

Coach,  356. 

Cleveland. 

.17 

.001 

.003 

Trace. 

.21 

9.0 

Dec.  29,  1886. 

2 

C.  C.  C.  & I. 

Coach,  301. 

Cincinnati. 

.15 

.005 

.016 

.001 

2.41 

26.3 

March  28,  1887. 

3 

Pan  Handle. 

Coach,  36. 

Columbus. 

.16 

.001 

.005 

Trace. 

.28 

6.6 

March  28,  1887. 

4 

Pan  Handle. 

Sleeper,  406. 

St.  Louis. 

.13 

.0005 

.002 

None. 

.18 

2.5 

March  29,  1887. 

5 

Ft.  Wayne. 

Coach,  26. 

Alliance. 

.18 

.001 

.004 

Trace. 

.50 

14.2 

March  29,  1887. 

6 

Ft.  Wayne. 

Sleeper,  383. 

Washington. 

.11 

.001 

.006 

Trace. 

.39 

8.4 

July  20,  1887. 

7 

B.  & O. 

Coach,  453. 

Sandusky. 

.09 

.001 

.003 

None. 

.25 

2.1 

July  20,  1887. 

8 

B.  & O. 

Sleeper,  505. 

Chicago. 

.19 

.001 

.004 

Trace. 

.28 

9.5 

July  20,  1887. 

9 

B.  & O. 

Coach,  350. 

Wheeling. 

.22 

.001 

.005 

.001 

1.60 

12.4 

1 [American  Chemical  Journal , Vol.  VIII,  page  190),  and  the  fact  learned  that  the  simpler 
form  gave  results  closely  comparable,  but  slightly  higher  than  those  obtained  by  the 
more  elaborate  apparatus. 

“The  samples  of  water  obtained  from  the  various  cars  were  submitted  to  the  usual 
examination  for  organic  impurities. 


55G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


“The  oxygen  required  for  oxidation,  free  and  albuminoid  ammonia,  nitrous  acid, 
chlorine,  and  total  solids  were  determined  in  each  sample.”  (See  page  555.) 

By  again  referring  to  chart  No.  1,  it  will  be  seen  that  71?  per  cent,  of  the  cars 
inspected  used  disinfectants  of  some  kind,  and  that  the  water  closets  iu  60  per  cent,  of 
these  cars  had  a had  smell. 

In  the  majority  of  the  cases  the  bad  smell  came  from  the  urinals. 

In  86?  per  cent,  of  the  cars  examined  there  were  found  tool  boxes,  consisting  usually 
of  an  ax,  sledge  and  saw,  placed  in  some  convenient  part  of  the  car,  while  76?  per  cent, 
carried  water  buckets,  and  only  40  per  cent,  carried  fire  extinguishers. 

83?  per  cent,  have  some  form  of  an  air-brake  attachment,  usually  consisting  of  a 
cord  running  along  the  side  of  the  car,  so  arranged  that  in  case  of  an  emergency  any 
person  can  pull  it  and  apply  the  air  brakes  to  the  train. 

Fifty  per  cent,  of  the  coaches  have  toilets  (by  this  we  mean  a washstand  and  towel, 
which,  in  the  common  coaches,  are  found  in  the  water-closet  apartment,  while  in  the 
sleepers  they  are  kept  separate). 

Of  the  toilet  apartments  and  water  closets — 

86?  per  cent,  were  ventilated, 


66? 

it 

of  washstands  were  clean, 

26? 

t( 

“ “ medium, 

6? 

it 

“ “ dirty; 

70 

a 

of  towels  were  clean. 

13 

a 

“ “ medium, 

17 

a 

“ “ dirty ; 

70 

a 

of  hoppers  were  ventilated, 

60 

a 

“ “ clean, 

10 

a 

“ “ medium, 

30 

a 

“ “ dirty ; 

37 

a 

of  urinals  were  ventilated, 

64 

it 

“ “ clean, 

23 

a 

“ “ medium, 

13 

a 

“ “ dirty; 

38 

a 

of  drips  to  urinals  were  clean, 

24 

a 

“ “ “ medium 

38 

a 

“ “ “ dirty; 

45 

a 

of  water  tanks  were  clean, 

34 

it 

“ “ medium, 

21 

a 

“ “ dirty. 

ladies’  toilets. 

100 

per  cent,  were  ventilated, 

100 

“ clean, 

100 

“ of  towels  were  clean ; 

100 

“ of  water  tanks  were  clean. 

64 

“ of  hoppers  “ ventilated, 

82 

“ “ “ clean, 

9 

“ “ “ medium, 

9 

“ “ dirty; 

73 

“ of  toilets  wore  disinfected, 

100 

“ “ had  no  odor, 

100 

“ “ were  carpeted, 

CONCLUSIONS  AND  SUGGESTIONS. 

The  results  of  these  investigations  have  called  our  attention  to  a number  of  inter- 
esting points  relative  to  railroad  sanitation. 

In  first-class  passenger  coaches,  constructed  with  the  greatest  of  mechanical  care,  at- 
large  expense,  there  should  not  be  such  extreme  changes  of  temperature  as  our  investi- 
gations have  shown  to  exist. 

We  must  either  attribute  it  to  the  faulty  construction  of  the  cars  or  to  improper  or 
defective  heating  and  ventilating;  with  such  universal  variations  of  temperature  as 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


557 


■were  found  to  exist  in  cars  of  first-class  construction,  made  of  first-class  material,  by 
skilled  workmen,  for  euterprising  and  progressive  companies,  we  are  led  to  the  natural 
and  legitimate  conclusion  that  the  fault  must  lie  with  our  present  system  of  heating 
and  ventilating  coaches. 

It  is  true  that  the  currents  of  air  outside  the  cars,  together  with  the  external  tem- 
perature, have  their  influence;  but  is  there  no  way  whereby  these  influences  may  be 
overcome?  and  these  extremes  of  temperature,  so  conducive  to  acute  diseases,  be  greatly 
modified  ? 

Putting  double  doors,  with  a sort  of  an  ante-room,  at  each  end  of  our  common 
coaches,  similar  to  that  of  the  sleeping-cars,  would,  no  doubt,  be  an  improvement  over 
the  present  methods  of  constructing  them;  yet,  if  you  will  refer  to  chart  No.  1,  you  will 
find  as  much  as  29°  difference  between  the  extremes  of  temperature  in  even  a sleeper, 
with  all  the  improvements  of  construction  science  has  suggested,  which  clearly  indi- 
cates that  there  is  something  else  at  fault  than  the  mere  construction  of  the  car  alone. 

If  you  will  go  a little  further  into  this  matter,  you  will  find  the  greatest  and  really 
most  important  difference  of  temperature  is  between  that  at  the  level  of  the  head  and 
that  at  the  surface  of  the  floor.  By  referring  to  chart  No.  1,  you  will  find  there 
was  found  to  be  as  much  as  30°  difference  in  one  instance  between  these  two  extremes, 
aud  that,  too,  in  a sleeper,  which  is  supposed  to  be  the  best  and  most  comfortably 
equipped  car  we  have,  for  the  privilege  of  riding  in  which  we  are  compelled  to  pay  an 
extra  fee;  and  yet  in  this  traveling  palace  the  minimum  difference  between  these  two 
extremes  of  temperature  was  found  to  be  12°  (that  is  by  taking  the  lowest  temperature  on 
the  floor  from  the  highest  at  the  level  of  the  head),  and  the  average  difference  estimated 
from  twenty-four  cars,  in  ordinary  winter  weather,  was  found  to  be  as  high  as  18°. 

With  these  facts  staring  us  in  the  face,  is  it  any  wonder  that  people  take  colds  and 
contract  severe  acute  diseases  while  traveling  in  our  passenger  coaches,  as  they  are 
heated  and  ventilated  at  the  present  day  ? 

By  referring  to  the  air  analysis,  table  No.  6,  you  will  find  that  in  these  same  cars 
above  referred  to  there  is  not  only  a great  variety  of  temperature,  but  also  a polluted 
atmosphere. 

For  example,  in  referring  to  chart  No.  1,  car  No.  319  (Pan  Handle  R.  R.)  will  be 
found  to  be  a sleeper,  and  only  contained  twelve  passengers,  but  showed  a difference 
between  the  temperature  at  the  bottom  of  the  car  and  the  level  of  the  head  of  29°,  and 
at  the  same  time  the  atmosphere  in  the  car  showed  13.35  parts  per  10,000  of  carbon 
dioxide  present  in  its  atmosphere,  the  highest  in  proportion  to  the  number  of  passen- 
gers of  any  car  examined,  which  certainly  demonstrates,  without  a question,  a decidedly 
imperfect  system  of  heating  and  ventilating;  and  yet  this  car  had  the  ordinary  provi- 
sions for  ventilating  found  in  the  majority  of  such  cars,  and  was  heated  by  a Baker’s 
hot-water  heater,  of  which  there  are  more  used,  as  shown  by  our  investigations,  than 
of  any  other  one  kind. 

Another  example  of  this  character  will  be  found  by  referring  to  car  No.  356  (C.  C.  C. 
& I.  R.  R.),  which  was  a ladies’  car,  heated  with  a Baker  heater,  of  which  there  was 
one  transom  and  eleven  drop  ventilators  open;  in  which  car  there  were  three  analyses  of 
the  air  made,  one  at  the  front  end  of  the  car,  when  there  were  thirty-two  passengers  in 
it,  which  showed  14.26  parts  per  10,000  of  carbon  dioxide  present;  another  at  the  mid- 
dle of  the  car,  when  there  were  twenty-nine  passengers  in  it,  which  showed  13.68  parts 
of  carbon  dioxide  present,  and  finally  one  at  the  rear  end  of  the  car,  when  there  were 
twenty-seven  passengers  in  it,  which  showed  11.53  parts  of  carbonic  acid  per  10,000. 

At  the  same  time  in  this  car,  the  thermometer  showed  a difference  of  14°  between 
the  level  of  the  head  and  the  surface  of  the  floor,  with  a variation  of  6°  between  the 
extremes  running  and  standing,  with  the  mercury  outside  at  15°  above  zero. 

The  horrifying  accidents  that  have  occurred,  alone  have  demonstrated  to  the  public 


558 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


mind  the  imperative  necessity  for  some  other,  safer,  and  if  possible,  a more  efficient  plan 
for  heating  our  passenger  coaches,  than  the  systems  now  in  use. 

Almost  universally  the  stoves  or  heaters  are  set  at  one  end  or  the  other  of  the  car,  or 
both,  and  in  the  case  of  a wreck  they  are  among  the  first  things  that  are  smashed 
up ; not  only  setting  fire  to  the  car,  but  cutting  off  all  means  of  escape  from  it,  excepting 
through  the  windows;  saying  nothing  of  the  valuable  space  they  occupy  in  every  car. 

It  seems  to  me  that  all  these  grave  objections  could  readily  be  remedied  by  a system 
of  heating  in  which  the  fire-box  of  the  heating  apparatus  would  be  inclosed  in  a steel 
case,  placed  underneath  the  middle  of  each  car,  which  steel  case  could  easily  be  con- 
structed to  serve  as  a hot-air  chamber,  as  well  as  a protection  against  fire  in  case  of  an 
accident;  to  this  hot-air  chamber  can  easily  be  attached  a pipe,  leading  from  an  air- 
pump  on  the  engine,  from  which  any  amount  of  pressure  desired  could  easily  be 
obtained,  and,  at  the  same  time,  by  a suitable  arrangement  with  a stop-cock  attach- 
ment, the  fire  could  be  supplied  with  any  amount  of  fresh  air,  at  will,  from  this  air 
pipe  or  the  hot-air  chamber,  and  yet  not  expose  it  in  any  way  to  the  car,  even  in  case 
of  an  accident;  then  by  placing  two  air  conduits  of  suitable  size  along  the  entire  length 
of  each  side  of  the  car,  underneath  the  windows,  say  eight  or  ten  inches  apart,  the 
upper  one  of  which  should  be  in  direct  connection  with  the  air-pump,  and  the  lower 


Fig.  8. 


Diagram  showing  proposed  system  for  heating  and  ventilating  passenger  coaches. 
a a,  hot-air  chamber,  b,  blower  for  fire,  c c,  registers  to  be  used  in  case  of  accident  to  air-pump. 
d d,  cold-air  conduit,  e e,  hot-air  conduit.  //,  short  conduits  connecting  hot  and  cold  conduits  with 
stop-cock  and  opening  for  exit  of  air  into  car.  g g , place  for  ventilating  attachment  for  urinal  or  hopper. 

one  connected  with  the  hot-air  chamber;  then,  by  connecting  these  two  conduits  opposite 
each  seat  by  a small  conduit,  at  each  end  of  which  there  should  be  a stop-cOck,  one  of 
which  should  be  marked  “ cold  air,”  and  the  other  one  “ hot  air;  ” then  by  having  an 
opening  in  the  middle  of  each  of  these  short  conduits  leading  into  the  car,  and  by  apply- 
ing a light  pressure  from  the  air-pump,  say  eight  or  ten  pounds  to  the  square  inch,  a 
regular  supply  of  fresh  air  could  be  forced  into  every  car,  regardless  of  the  direction  the 
car  was  running,  or  whether  it  was  running  at  all,  or  the  condition  of  the  external 
atmosphere.  (See  Fig.  8.) 

At  the  same  time,  to  insure  perfect  heating  of  the  car,  and  the  removal  of  the  cold, 
foul  air  at  the  bottom  of  the  car,  a foul-air  ventilator  should  be  placed  at  each  end  of 
every  car,  and  so  constructed  as  to  be  opened  or  closed  at  will.  The  one  at  the  front  end 
of  the  car  should  always  be  kept  closed,  and  the  one  at  the  rear  end  always  kept  open. 

These  ventilators  should  be  placed  at  a level  with  the  floor,  and  open  into  a foul-air 
conduit  that  should  pass  out  of  the  car,  say  a foot  above  the  top,  and  be  large  enough 
to  receive  all  the  foul  air  as  fast  as  it  would  accumulate,  and  being  at  the  floor  would 
not  only  remove  the  foul  air,  but  also  the  cold  stratum  of  air  that  always  accumulates 
at  the  bottom  of  the  car. 

By  means  of  a stop-cock,  and  a connecting  conduit  with  one  of  the  pressure-air 
pipes,  a constant  ascending  current  could  be  insured,  if  found  necessary  in  the  foul-air 
conduit,  which  I am  satisfied  would  seldom,  if  ever,  be  needed. 

With  this  arrangement  there  should  be  no  ventilators  of  any  kind  at  the  top  of  any 
car,  and  no  windows  should  be  allowed  open,  for  just  as  soon  as  a ventilator  is  open  at 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


559 


the  top  of  a car;  it  allows  the  warm,  pure  air  to  escape,  and  thus  not  only  wastes  the 
heat,  but  allows  the  cold,  foul  air  at  the  bottom  of  the  car  to  remain,  to  the  discomfort 
of  the  passengers. 

By  such  a plan  each  seat  would  be  supplied  with  a fresh  supply  of  either  warm  or 
cold  air,  or  a mixture  of  both,  by  a simple  turning  of  the  stop-cock  opposite  each  seat, 
not  only  giving  individual  ventilation,  which  is  especially  so  essential  in  sleeping  cars, 
but  at  the  same  time  ventilating  and  heating  the  whole  car,  at  the  will  of  its  occupants, 
regardless  of  external  influences,  which  should  be  governed,  so  far  as  the  heating  of  the 
car  is  concerned,  by  thermometers,  kept  at  suitable  points  in  each  coach,  with  printe  1 
• instructions  accompanying  them  as  to  the  proper  average  temperature  the  car  should  be 
kept  at. 

By  such  a method  it  will  be  readily  seen  that  a constant  supply  of  warm,  pure  air 
coming  in  at  the  sides  of  the  car  would  soon  heat  it  evenly  all  over,  and  by  its  pressure 
would  constantly  drive  the  cold,  foul  stratum  of  air  at  the  bottom  of  the  ear  out 
through  the  foul-air  ventilators,  and  thus  not  only  ventilate,  but  heat  the  car  perfectly 
and  scientifically  throughout,  and  thus  avoid  all  unnecessary  draughts  from  open  win- 
dows or  ventilators,  such  as  are  now  found  in  almost  every  coach  you  enter,  whether 
first-class  or  the  lowest  grade  of  emigrant  cars. 

For  emergencies,  in  case  of  failure  of  the  air  pump,  or  the  detachment  of  the  engine 
from  the  train,  two  hot-air  pipes,  leading  from  the  hot-air  chamber  into  the  car,  with 
suitable  registers,  can  easily  be  arranged  for,  by  which  each  car  could  be  heated  directly, 
the  same  as  from  an  ordinary  furnace,  until  the  defects  in  the  air  pressure,  whatever 
they  might  be,  were  remedied,  when  the  registers  could  be  closed  air  tight,  and  the 
pressure  from  the  air  pump  again  applied. 

Such  a system  for  heating  and  ventilating  would  certainly  have  several  advantages 
over  the  plan  now  in  use. 

1.  It  would  provide  for  an  equal  distribution  of  heat  throughout  the  car,  regardless 
of  the  weather  outside,  or  whether  the  train  be  running  or  standing. 

2.  It  would  furnish  a constant  supply  of  fresh  air  to  each  seat,  regardless  of  the 
external  atmospheric  pressure  or  the  direction  the  train  be  running,  and  in  such  amounts 
and  at  such  a temperature  as  the  occupant  might  desire,  and  thus  avoid  the  very 
objectionable  habit  of  opening  the  windows  or  doors  for  a supply  of  fresh  air. 

3.  It  would  be  decidedly  safer  thau  having  a heater  at  each  end  of  a car  should  a 
wreck  occur,  and  much  cheaper  and  more  efficient  than  either  hot  water  or  steam  from 
an  engine,  and  equally  as  safe  and  much  better  practically. 

4.  By  this  method  the  water  closets,  as  well  as  the  urinals  and  hoppers  in  them, 
could  be  constantly  and  thoroughly  ventilated,  at  a trifling  expense. 

5.  While,  last,  but  not  least,  by  this  system  the  room  now  occupied  by  heaters  in 
each  car  would  be  vacated  aud  could  be  used  for  a better  purpose. 

The  use  of  lamps,  gas,  and  even  candles,  for  the  lighting  of  coaches,  should  be 
promptly  abandoned.  Candles  are  not  only  dangerous  in  case  of  a wreck,  but  trouble- 
some, dirty  and  inefficient ; while  gas,  owing  to  its  bulk  and  dangerous  properties  in 
the  case  of  a wreck,  where  it  is  liable  to  either  smother  people  (for  which  reason  it  has 
already  been  abandoned  by  some  roads)  or  explode  and  set  fire  to  surrounding  struc- 
tures, make  it  a dangerous  element  to  use  in  railroad  service. 

Although  lamps  are  in  general  use  throughout  the  country  for  the  lighting  of  rail- 
road coaches,  yet  I consider  them  even  more  dangerous  than  either  candles  or  gas  in 
case  of  an  accident.  They  are  almost  certain  to  become  broken,  and  the  oil  spilt  over 
the  car,  which  is  easily  ignited,  and  in  an  instant  gets  beyond  all  control. 

The  safety  and  efficiency  of  the  incandescent  light  for  the  lighting  of  railroad  coaches 
should  certainly  place  it,  without  a question,  beyond  all  doubt  the  ideal  method  for 
lighting  railroad  cars.  Its  success  for  this  purpose  has,  to  my  own  knowledge,  already 
been  thoroughly  demonstrated  on  the  cars  of  the  electric  street  railroad  in  my  own  city, 


500 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


and  besides,  I have  been  informed  that  its  use  on  one  or  more  of  our  Eastern  railroads 
has  proven  successful  and  satisfactory. 

Then,  if  it  is  safe,  efficient,  reasonable  in  price,  does  not  burn  up  the  oxygen  of  the 
air  in  the  car,  and  goes  out  immediately  when  impaired  by  an  accident,  without  the 
least  danger  of  igniting  the  surrounding  structures,  why  should  we  hesitate  to  adopt  it, 
and  do  away  with  the  use  of  lamps,  which  are  certainly  as  expensive,  much  more  dirty 
and  troublesome,  less  efficient  aud  decidedly  more  dangerous  ? 

AIR  AND  WATER  ANALYSIS. 

In  regard  to  the  air  and  water  analysis,  Prof.  Howard  remarks  that  “an  examina- • 
tion  of  the  results  obtained  shows  several  points  of  interest.  The  results  obtained  in 
summer,  when  doors  and  windows  are  open,  show  that  under  these  circumstances  the  ' 
air  of  the  car  contains  slightly  more  than  the  normal  quantity  of  carbon  dioxide.  The 
proportion  is  from  4.26  to  4.90  parts  in  10,000,  while  the  air  in  the  surrounding  fields 
probably  contained  about  3 parts  in  10,000. 

“In  winter,  with  closed  doors  and  windows,  the  results  are  quite  different.  It  may 
be  noted  that  the  quantity  of  carbon  dioxide  present  is  largely  proportional  to  the 
number  of  passengers  in  the  car.  The  smokers,  which  generally  contained  a less  num- 
ber of  passengers  than  the  ladies’  cars,  had  an  atmosphere  that  contained  less  carbon 
dioxide  than  that  in  the  more  crowded  ladies’  cars.  The  odors  in  the  smokers  were 
frequently  more  offensive,  for  reasons  that  will  readily  suggest  themselves. 

“ The  air  of  the  sleepers  was  not  generally  found  to  be  lower  in  carbon  dioxide  than 
that  of  the  coaches,  as  might  be  expected  to  be  the  case,  both  from  the  smaller  number 
of  passengers  and  from  the  presumably  better  means  of  ventilation.  A large  part  of 
the  ventilation  of  the  coaches  is  obtained  by  the  opening  of  the  doors  at  stations,  and 
in  the  sleepers,  where  this  prevails  to  a less  extent,  there  is  less  change  of  air  from  this 
cause  and  the  carbon  dioxide  rapidly  rises. 

“ An  instructive  experiment,  as  showing  the  ventilation  obtained  by  doors  and  win- 
dows, was  made  on  the  Pan  Handle  R.  R.  The  doors  and  windows  of  Coach  36,  with 
twenty-three  passengers,  had  remained  closed  for  thirty-five  minutes.  The  carbon 
dioxide  rose  to  10.78  parts.  The  doors  were  opened  for  two  minutes;  a current  of  fresh 
air  swept  through  the  car,  and  the  carbon  dioxide  sank  to  4.22  parts,  or  but  little  more 
than  the  normal  quantity. 

“This  proves  that  the  present  system  of  ventilation  in  coaches,  and  even  in  sleepers, 
is  far  from  satisfactory. 

‘ ‘ The  mixture  of  ice  aud  water  gave  fairly  satisfactory  results,  and  it  is  probable 
that  the  quality  of  the  water  was,  in  many  cases,  improved  by  the  mixture  with  the  ice.  ’ ’ 

The  assertion  made  by  Prof.  Howard,  in  regard  to  the  ice  improving  the  water,  is 
no  doubt  true  where  the  water  is  very  bad  and  the  ice  very  good ; but  where  you  have 
good  water  to  start  with,  the  addition  of  commercial  ice  will  certainly  not  improve  it. 

The  objectionable  habit  of  using  roller  towels,  or  those  in  common  use,  for  a promis-  . ; 
cuous  lot  of  patrons,  should  be  speedily  done  away  with,  and  nothing  but  small,  indi- 
vidual towels  be  allowed  used  under  any  circumstances. 

In  the  protection  against  emergencies,  we  found  that  83J  per  cent,  of  the  coaches 
were  supplied  with  an  air-brake  attachment,  described  heretofore  in  this  paper,  and 
which,  practically,  I consider  of  little  real  value. 

In  fact,  the  air  brake  itself,  although  in  almost  universal  use,  has,  in  my  opinion, 
seen  its  best  day,  so  far  as  the  real  safety  of  passengers  is  concerned,  in  emergencies,  >, 
unless  improved  upon. 

It  is  true,  when  air  brakes  work  at  all,  they  usually  work  well;  but  it  is  also  too 
true  that  when  it  fails  on  a single  car,  it  fails  on  the  whole  train  connected  with  that  car. 

Its  great  liability  to  fail,  and  fail  often  when  most  needed  and  least  expected,  makes 
it  a dangerous  element  in  railroad  service;  for  when  depended  upon,  aud  it  fails,  as  I 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  561 


am  informed  was  the  case  only  a few  weeks  ago  in  this  very  city,  a whole  train  load  of 
lives  is  suddenly  placed  in  imminent  peril. 

When  we  stop  to  consider  that  a very  large  percentage  of  all  the  railroad  accidents 
occurring  to  passenger  trains  are,  directly  or  indirectly,  the  result  of  defective  air 
brakes,  we  are  led,  as  sanitarians,  to  look  for  something  better,  safer  and  more  reliable. 

From  the  most  reliable  information  I can  obtain  on  this  subject,  I am  informed  that 
a good  automatic  brake  is  much  more  reliable  and  equally  as  efficient,  and  much  more 
simple  in  construction,  and  when  the  brakes  on  one  or  more  cars  in  a train  get  out  of 
order,  it  does  not  impair  the  usefulness  of  the  brakes  on  the  remainder  of  the  cars  in 
the  train;  and  thus  it  makes  them  decidedly  the  safer  and  more  reliable  brake  for  rail- 
road service,  from  a sanitary  standpoint,  than  any  other  now  in  use,  so  far  as  it  has  been 
possible  to  practically  demonstrate  this  question. 

You  will  notice  that  36f  per  cent,  of  the  urinals  have  ventilators,  and,  further,  that 
nearly  all  the  bad  smell  in  the  water  closets  came  from  either  the  urinals  or  their  drips, 
of  which  there  were  60  per  cent,  of  the  whole  number  examined  giving  off  a bad  odor. 

In  this  direction  I would  recommend  less  plumbing  work  about  the  urinals  than  is 
found  at  present,  simply  making  a large  opening  similar  to  that  of  the  hoppers,  which, 
like  the  hoppers,  would  have  free  ventilation,  and  no  place  for  stale  urine  to  accumu- 
late, which,  with  the  moderate  use  of  some  good,  reliable  disinfectant,  would  soon  do 
away  with  all  these  disagreeable  odors,  when  the  gentlemen’s  water  closet  would  show 
as  good  a record  as  the  ladies’  does  now. 

I cannot  close  this  paper  without  referring  to  the  water  tanks  as  usually  found  in 
our  coaches,  of  which  201  per  cent,  were  found  dirty,  among  which  was  discovered  one 
with  a baby’s  soiled  diaper  in  it. 

Many  of  the  tanks  are  placed  so  as  to  open  inside  of  the  water  closet  apartment,  and 
I am  credibly  informed  by  railroad  employes,  who  have  had  abundant  opportunities 
for  knowing,  that  it  was  not  an  infrequent  occurrence  to  find  babies’  diapers,  dirty  rags 
and  filth  of  that  character  dumped  into  the  water  tanks  of  our  passenger  coaches. 

So  frequently  was  this  the  case  that  some  of  the  railroads  have  made  their  cars  more 
recently  with  the  water  tanks  opening  on  the  top  of  the  car,  while  others  have  placed 
them  in  plain  view  in  the  car,  where  filth  of  that  character  could  not  be  so  easily  intro- 
duced into  them  without  being  detected. 

The  analysis  of  the  water,  with  a few  exceptions,  shows  that  a very  fair  quality  of 
water  was  supplied  the  passengers  on  the  roads  examined;  yet  the  custom  of  dumping 
the  ice  used  into  the  water  should  be  dispensed  with,  and,  instead,  a water  tank  used 
that  was  so  constructed  as  to  permit  of  the  ice  being  packed  around  the  outside  of  the 
water  can  proper,  which  should  be  porcelain  lined,  and  so  arranged  as  to  be  easily  got 
at  and  cleaned,  which  is  the  great  objection  to  those  opening  at  the  top  of  the  car; 
while  the  tops  to  these  refrigerators  should  not  only  be  double,  but  locked  on,  and  no 
person  furnished  with  a key  except  the  proper  railroad  employes,  and  they  should  be 
held  responsible  for  their  sanitary  condition. 

With  such  an  arrangement  the  drinking  water  could  be  kept  clean  and  free  from 
“foreign  or  domestic”  filth,  the  water  kept  cool,  but  not  ice  cold,  and  at  the  same 
time  free  from  the  many  impurities  so  frequently  found  in  commercial  ice. 

On  the  whole,  however,  we  think  the  railroads  examined  will  compare  very  favor- 
ably with  the  great  mass  of  American  railroads,  which,  in  turn,  will  compare  just  as 
favorably  with  those  of  the  world. 

Yet  there  are  many  things  pertaining  to  the  sanitary  interest  of  our  passenger  coaches 
which  can  still  be  very  much  improved  upon,  and  if  this  investigation,  crude  and 
imperfect  as  it  was,  will  only  be  the  means  of  calling  attention  to  and  remedying  any 
one  of  these  sanitary  imperfections,  I will  feel  that  I am  amply  paid  for  all  my  trouble, 
and  that  my  labors  in  this  direction  have  not  been  in  vain. 

Vol.  IV— 36 


TEMPER  ATI!  EE  CHART  NO.  1,  FAHRENHEIT’S  SCALE. 


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t^p-r^i^  r^p'-t^  xxx  xx  xo  o oo  oo  xx 

PZ 

ioxox  ci  x ci  ooo  xp-  xo  ci  -r  10  xx  oo 

P~  X X X P~  P-  P-  I"  X XX  XX  O OO  OO  XX 

"is  I 

X-f  XCl  CIO®  XPN  1^0  OO  X r^x  Cl  Cl  oci 

P-XXX  r-  t^  XXP-  XO  XO  O OO  OO  XX 

•jwo  joapisnr  paw  apis^no 
saraaJixa  uaaAi^aq  aonaaajyiQ 

O — 1 Cl  — 1 OOX  XXX  OCI  CIX  ^ X T}1 -f  r}*  X 

XXXX  lO  lO  lo  1C  »o  to 

ubd  jo  apisjno  ajnjnjadraax 

15 

above0 

15 

above  ° 

16 

above0 

88 

above0 

88 

above  ° 

89 

above0 

90 

above  ° 
89 

above0 

76 

above  ° 

•JOjiqijTiaA  jo  pnix 

Side  Sash 

Register 

Register 

Register 
Register 
Register 
Register 
Drop  Sash 
Register 

•pasn  jajwaq  jo  paix 

Bissell 

hotair 

Bissell 
hot  air 

Bissell 
hot  air 

Stoves 

Spear 
hot  air 

Spear 
hot  air 

Spear 
hot  air 

Baber’s 

Meyer 
hot  air 

•jwo  jo  paix 

Ladies’ 

Ladies’ 

Smoker 

Smoker 
Ladies’ 
Ladies’ 
J.adies’ 
Sleeper. 
Lad  ies’ 

uno  jo  jaqranx 

X X X P^  X O — I »C  ® 

d — X 1010XX0  1C 

■*r  ■'T  ■'T  ■vr  LO  X 

•pBOH 

Fort 

Wayne 

Fort 

Wayne 

Fort 

Wayne 

B.  & 0. 

B.  & 0. 

B.  it  0. 

B.  A 0. 

B.  it  0. 

B.  4 0. 

•ajB(x 

*2  'ff  <5*  £ A £ £ £ 

C5  j o • o*  o • o • o • 

oi  d S d^5  dS  cig*  dS  d s dg 

iS  w w 3 = 333=j 

CHART  HO.  2. 

A TABLE  SHOWING  TI1E  GENERAL  SANITARY  CONDITION  OF  THIRTY  PASSENGER  CARS  INSPECTED. 


1 

1st. 

2d. 

Sd. 

4th. 

5th. 

6th. 

7th. 

8 th. 

9th. 

10th. 

nth. 

12th. 

13tli. 

14th. 

15th- 

16th. 

17th. 

18th. 

19th. 

20th. 

2W- 

22d. 

23d. 

24th. 

25  th. 

26tli. 

27  th. 

28lh. 

29  th. 

80th. 

Qonornl  Romurks, 

Name  of  the  Railroad 

Number  of  the  Cor 

C.  C,  C. 
A 1. 
355 

C.  C.  C. 
A I. 
148 

C.  C.  C. 

A 1. 
42 

C.  C.  C. 
A I. 
146 

C.  C.  C. 
A I 
346 

c.  c.  e. 

A I. 
88 

C.  C.C 
& I. 
153 

C.  C.  C. 
A I. 
356 

C.  C.  C. 
A I. 
40 

C.  0.  C. 
A I. 

84 

C.  C.  C. 
A I. 
301 

C.  C.  C. 
A I. 
346 

Tan 

Handle. 

51 

Pan 

Handle. 

36 

nl 

n 

He. 

Pan 

Handle. 

319 

Pan 

Handle. 

406 

Pan 

Handle. 

392 

Ft. 

Wayne. 
" Metis.” 

Ft. 

Wayne. 

383 

Ft. 

Wayne. 

291 

Ft. 

Wayne. 

26 

Ft. 

Wayne. 

16 

Ft. 

Wayne 

B.&O. 

B.  A O. 

B.  A O. 

B.  AO. 

B.  A O. 

B.  A 0. 

Kind  of  Car 

Hate  of  lns|*ection 

Ladies’. 
Dec.  10, 
1886. 

Smoker. 
Dec,  10, 
1886. 

Sleeper. 
Doc.  10, 
1886. 

Smoker. 
Dee.  16, 
1886. 

Ladies’ . 
Dee.  16. 
1886. 

Sleeper. 
Dec.  16, 
1886. 

Smoker. 
Dec.  29, 
1886. 

Ladles'. 
Dec.  29, 
1886. 

Sleeper. 
Dec.  29, 
1886. 

Sleeper. 
Dec.  29, 
1886. 

Smoker. 
Dec.  29, 
1886. 

Ladles’. 
Dec.  29, 
188G. 

Smoker. 
March  28, 
1887. 

Ladies’. 
March  28, 
1887. 

Ladies'. 
March  28, 

1887. 

Sleeper. 
March  28, 
1887. 

Sleeper. 
March  28, 
1887. 

Sleeper. 
March  23, 
1887. 

Sleeper. 
March  29, 
1887. 

Sleeper. 
March  29, 
1887. 

Sleeper. 
March  29, 
1887. 

Ladies'. 
March  29. 
1887. 

Ladies'. 
March  29, 
1887. 

Smoker. 
March  29, 
1387. 

Smoker. 
July  20, 
18S7. 

Ladies’. 
July  20, 
1S87. 

Ladies’. 
July  20, 

Ladies’ . 
July  20, 
1887. 

Sleeper. 
July  20, 
1887. 

Ladies’. 
July  20, 
1887. 

A. -Protection  against  Emergencies. 

1.  Is  there  an  air-brake  attachment  ? 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

Yes. 

Yes. 

Yes. 

No. 

Yes. 

Yes. 

Yes. 

No. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

No. 

Yes. 

No. 

No. 

Yes. 

No. 

No. 

No. 

No. 

Yes. 

No. 

Yes. 

No. 

No. 

No. 

No. 

Yes. 

This  hasreforoucc 
to  a special  a i r- 
brakenttnclimcnl  to 
each  car. 

3.  Are  fire  extinguishers  carried  ? 

Yos. 

No. 

Yes. 

No. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

No. 

Yes. 

Yes. 

Yes. 

Yes. 

No. 

No. 

Yes. 

Yes. 

Yes. 

1 

0. 

No. 

No. 

No". 

Yos. 

Yes. 

No. 

No. 

Yes. 

No. 

No. 

Yes. 

No. 

Yes. 

1 es. 

B.— Artificial  Lighting  of  the  Car. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

N 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No, 

No. 

No. 

No. 

Candles  nro  sol- 

wo. 

wo. 

lorn  used  on  first- 

Yes. 

No. 

Ym 

Yes. 

No. 

Yes. 

No. 

Yes. 

No. 

v 

y 

y 

Yes. 

No. 

Yes. 

No. 

Yos. 

Yes. 

class  trains. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

Gas  was  used  n 

No. 

I\u. 

lew  years  ago  on  the 

C.— Toilets.  Gentlemen’s  Toilet,  or  in  com- 
mon use,  for  both  Sexos. 

Ponn’a  Road. 

Ym 

No. 

Yes.* 

Pipe. 

None*. 

Yes. 

Yes. 

Drop. 

Marble. 

Clean. 

Indi- 

Voa 

Yes. 

Yes. 

Drop. 

Marble. 

Fair. 

Roller 

Ym 

y 

N 

No. 

Yes.* 

Pipe. 

None. 

Nono. 

Yes. 

Yes. 
Drop. 
Marble. 
Cleau. 
Roller 
and  indi- 

No. 

Yes* 

Pipe. 

None. 

None. 

This  has  reference 

2.  Is  it  ventilated? 

Yes.4 

Pipe. 

None. 

None. 

Yes.4 

Pipe. 

Nono. 

None. 

Yes. 

No. 

No. 

Yes. 

Yes  4 

Yes. 

Yes. 

Yes. 

Yes* 

Pipe. 

None. 

None. 

No. 

No. 

Yes* 

Pipe. 

None. 

None. 

Yes. 

Drop. 

Marble. 

Medium. 

Indi- 

Yes. 

Yes. 
Drop. 
Marble. 
Clean. 
Roller 
and  indi- 
vidual. 

Yes. 
Drop. 
Marble. 
Clean. 
Roller 
and  indi- 
vidual. 

Yes. 

Pipe. 

Marble. 

Dirty. 

Roller. 

Yes.* 

Pipo. 

None. 

None. 

Yes.4 

Pipo. 

Nono. 

None. 

Yes.* 

Pipe. 

None. 

Yes.* 
Pi, a.. 
None. 

Yes.* 

Pipe. 

None. 

to  a washstniid  In 
addition  to  a closet. 

I What  kind  of  washstand  is  used  ? 

5.  In  what  condition  is  it? 

Marble. 

Clean. 

Roller 

Marble. 

Medium. 

Roller. 

Marble. 

Clean. 

Roller 

None. 

None. 

Marble. 

Clean. 

Roller. 

Marble. 

Clean. 

Indi- 

Marble. 

Clean. 

Indi- 

vidual. 

Marble. 

Medium. 

Roller. 

None. 

None. 

Marble. 

Clean. 

Single. 

vidual. 

single. 

vidual. 

vidual. 

None. 

Dirty. 

Zinc. 

Clean. 

Zinc. 

Cleun. 

Zinc. 

Clean. 

Zinc. 

Clean. 

Zinc. 

Clean  and 

Clean, 

Zinc. 

S.  What  kind  of  water  tank  is  used? 

Zinc. 

Zinc. 

Zinc. 

Zinc. 

Ziuc. 

Zinc. 

Zinc. 

Zinc. 

Zinc. 

Zinc. 

Zinc. 

Zinc. 

Zinc. 

Zilic ; 
filled  at 
top  of  car. 

Zinc. 

dirty. 

Zinc. 

Zinc; 
filled  at 
top  of  cor. 

Zinc; 
tilled  at 
top  of  cur. 

Ziuc; 
filled  at 
top  of  car 

Zinc. 

Zinc. 

Zinc. 

Porceluiu 

lined. 

Zinc. 

This  only  refers 
to  the  tanks  for 
carrying  drinking 
wator. 

Clean. 

Clean. 

Clean. 

Clean. 

Clean. 

Clean. 

Dirty. 

Medium. 

Medium. 

Medium. 

Medium. 

Medium. 

Med 

Dirty. 

Clean. 

Clean. 

Dirty. 

Dirty. 

Medium. 

Clean. 

Cleau. 

Clean. 

Clean. 

It).  What  kind  of  hopper  is  used? 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain; 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain 

Porcelain. 

Porcelain 

Porcelain 

No. 

No. 

No. 

Clean. 

Porceluiu 

No. 

Clean. 

Porcelain 

Dirty. 

No. 

No. 

Clean. 

Porcelain 

No. 

Medium. 

Porceluiu. 

No. 

Clean. 

Porcelnln. 

Dirty. 

Clean. 

Clean . 

Clean. 

Clean. 

Dirty. 

Very 

dirty. 

Porcelain. 

Dirty. 

Porcelain. 

Dirty. 

Porcelain. 

Dirty. 

Porcelain. 

Clean. 

Porcelain 

Clonn. 

Porcelain. 

13.  What  kind  of  urinal  is  used  ? 

Porcelain. 

Metallic. 

Porcelain. 

Porcelain. 

Porcelain 

Porcelain. 

Yes. 

Porcelain. 

Porcelain. 

Porcelain. 

Porcelain 

Porcelain. 

Porcelain. 

Porcelain. 

‘lain. 

Porcelain 

Porcelain. 

Porceluin. 

Porcelain. 

Porcelain. 

Porcelain. 

No. 

Clean. 

Porcelain. 

Medium. 

15.  lu  what  condition  is  it? 

Hi.  Whnl  kind  of  drip  to  urinal? 

I«.  lu  what  condition  is  it? 

Medium. 

Porcelain. 

Medium. 

Dirty. 

Metallic. 

Dirty. 

Clean. 

Copper. 

Filthy. 

Zinc. 

Dirty. 

Medium. 

Zinc. 

Medium. 

Clean. 

Porcelain. 

Clean. 

Filthy. 

Zinc. 

Filthy. 

Clean. 

Porcelain. 

Medium. 

Clean. 

Copper. 

Clean. 

Medium. 

Porcelain 

Medium. 

Clean. 

Medium. 

Ziuc. 

Dirty. 

Medium. 

Porcelain. 

Dirty. 

Medium. 

Porcelain. 

Medium. 

Clfcau. 

Porcelain 

Dirty. 

Clean. 

Porcelain 

Clean. 

Clean. 

Porcelain 

Clean. 

Clean. 

Porcelain 

Clean. 

Clean. 

Porceluin. 

Clean. 

Clean. 

Porcelain. 

Medium. 

Medium. 

Porcelain. 

Dirty. 

Dirty. 

Porcelain 

Dirty. 

Clean. 

Porcelain 

Clean. 

Clean. 

Porcelain 

Dirty. 

Clean. 

Porcelain 

Clonn. 

Clean. 

Porcelain. 

Dirty. 

Yes. 

Clean . 
Porcelain. 
Cleau. 

Clean. 

Porcelain. 

Clean. 

If*  lir  *■"  * ■ * 

Yes. 

No. 

Yes. 

No. 

No. 

Yes. 

Yes. 

Yes. 

Yos. 

Yes. 

No. 

No. 

No. 

Yes. 

Yes. 

Yos. 

Yes. 

No. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yos. 

Yes. 

19.  What  kind? 

Carbolic 

Liquid. 

Carbolic 

Carbolic 

Liquid. 

Granules 

Ice. 

“Star." 

"Slur." 

“Star." 

"Star." 

“ Star." 

Ice. 

ice. 

Ico. 

Ice. 

Ice. 

Ice. 

Ice. 

Camphor 

lee. 

Daily. 

No. 

Ico. 

Daily. 

No. 

Daily. 

No. 

Daily. 

No. 

Daily. 

Yes. 

Daily. 

Yes. 

Daily. 

No. 

Daily. 

No. 

Daily. 

Yes. 

Dally. 

No. 

Daily. 

No. 

Daily. 

No. 

Daily. 

Yes. 

Daily. 

No. 

Daily. 

Slight. 

Daily. 

Yes. 

Urinal. 

No. 

Daily. 

Slight. 

Daily. 

Yes. 

Daily. 

No. 

Daily. 

Dally. 

No. 

21.  Is  there  any  sinell  *. 

Yes. 

Yes. 

Slight. 

\ Yes. 

Yes. 

Drip  and 

Yes. 

Urinal 

Yes. 

Slight. 

Yes. 

23.  Is  the  toilet  carpeted  ? 

No. 

Yes. 

No. 

No.  | 

Yes. 

No. 

No. 

Yes. 

Yes. 

No. 

No. 

No. 

liogper. 

0. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

No. 

Yos. 

No. 

Ladies’  Toilet. 

Yes. 

Yos. 

Pipe. 

Pipe. 

Pipe. 

Pipe. 

Pipe. 

Pipe. 

Pipe. 

Drop. 

Pipo. 

Marble. 
Clonn. 
Roller 
mid  indi- 
vidual. 
Clenn. 

5.  Whnt  kind  of  towels  are  supplied?...  

Indi- 

vidual. 

Single. 

Indi- 

vidual. 

Indi- 

vidual. 

Clean. 

Indi- 

vidual. 

Indi- 

vidual. 

Clean. 

Indi- 

vidual. 

Clean. 

Roller 
and  indi- 
vidual. 
Clean. 

Roller 
and  indi- 
vidual. 
Clean. 

Indi- 

vidual. 

•4 

4 

4 

4 

4 

4 

4 

4 

4 

3 

4 

4 

4 

4 

4 

V 

4 

Tills  only  refers 

= 

=: 

Zinc. 

= 

— 

a 

a 

Zinc. 

Zinc. 

Ziuc. 

Zinc. 

Zinc. 

Zinc. 

z: 

fg 

S 

3 

— 

ra 

"3 

Double 

a 

to  the  tanks  lor 
carrying  drinking 
wator. 

H 

H 

H 

H 

3 

H 

H 

£ 

H 

-< 

H 

H 

H 

£ 

H 

H 

H 

8.  In  what  condition  is  it?..... 

£ 

S 

Clean. 

3 

£ 

Clean. 

3 

"3 

Clean. 

Clonn. 

£ 

£ 

£ 

£ 

3 

Clean. 

Clean. 

Clean. 

Clean. 

Clean. 

Clean. 

£ 

£ 

3 

£ 

8 

3 

3 

Clean. 

% 

9.  What  kind  of  hopper  is  used?. 

3 

"2 

Porcelain 

>4 

3 

Porcelain 

No. 

3 

3 

Porcelain 

No. 

Porcelain 

■8 

4) 

•a 

3 

3 

3 

3 

Porcelain 

hopper. 

Porcelain 

Porcelain 

Porcelain 

Porcelain 

3 

3 

3 

3 

3 

•a 

3 

3 

Porcolnln. 

3 

11  In  what  condition  is  it? 

'A 

Clean. 

Yes. 

A 

A 

Clean. 

Yes. 

A 

A 

Cleon. 

Medium. 

A 

A 

A 

A 

5 

Clean. 

No. 

Clean. 

Clean. 

Clean. 

Dirty. 

Yes. 

A 

A 

A 

A 

A 

A 

Clenn. 

A 

13.  What  kind? 

Liquid. 

Liquid. 

Crane's. 

“Star. 

“Star." 

"Star." 

Camphor 

14.  How  often? 

15.  Is  there  any  smell  ? 

Daily. 

No. 

Daily. 

No. 

Daily. 

No. 

Daily. 

No. 

No. 

Daily. 

No. 

No. 

No. 

Daily. 

No. 

Daily. 

No. 

Dully. 

No. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yes. 

Yea. 

' 

* Whore  there  is  no  toilet,  the  ventilation 


refers  to  the  water  closet. 


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SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  565 


DISCUSSION. 

Dr.  A.  N.  Bell,  of  New  York. — In  traveling  on  railroads  I always  keep  my  eyes 
about  me,  to  find  out  what  cau  be  seen.  In  traveling  once,  my  wife  was  with  me, 
we  stopped  at  a small  village,  not  the  regular  place  for  supplying  the  water  tanks 
in  the  sleepers.  I saw  one  of  the  porters  go  out  and  fill  bucket  after  bucket,  and 
empty  them  into  our  drinking-water  tank,  from  a foul  and  filthy  little  rivulet  carrying 
the  drainage  and  sewerage  from  some  of  the  houses  of  the  hamlet.  I am  in  favor 
of  this  most  important  matter  being  brought  to  the  attention  of  our  legislators, 
as  well  as  the  criminal  carelessness  with  which  the  modern  railroad  is  conducted, 
resulting  iu  disease  and  deaths , whose  numbers  are  appalling. 

Dr.  Scott,  of  Cleveland,  Ohio. — This  subject  is  of  vast  and  national  importance. 
I have  traveled  on  cars  to  a considerable  extent,  and  generally  notice  what  is  going 
on.  I have  seen  soiled  baby’s  diapers  thrown  into  the  water  tank,  i.  e.,  not  seen 
them  thrown  in,  but  found  them  there.  The  privies  on  the  cars,  and  especially  in 
some  of  the  stations,  notably  Pittsburg,  are  filthy  beyond  conception.  A man  may 
carry  home  the  seeds  of  lifelong  infection  from  these  sources.  The  use  of  the  roller 
towel  is  abominable ; individual  towels  should  invariably  be  furnished  and  the  other 
abolished.  With  regard  to  air-brakes,  their  day  has  nearly  passed ; we  must  have 
an  automatic  brake.  In  coming  down  the  mountain  the  other  day,  it  was  desired  to 
stop  the  train  at  a certain  point  in  order  to  allow  the  passengers  to  see  some  object 
of  interest ; the  engineer  found  that  the  air-brakes  would  not  work,  and  he  could  not 
check  the  train  at  the  desired  point.  If  this  had  been  a track  road  and  another 
train  approaching,  we  would,  in  all  probability,  have  been  hurled  down  a precipice 
one  hundred  feet  high.  This  matter  should  be  prominently  agitated  until  some  safe 
and  reliable  brake  can  be  adopted. 


THE  HISTORY,  PRACTICAL  APPLICATION  AND  EFFICIENCY  OF 
STEAM  AS  A DISINFECTANT. 

L’HISTOIRE,  L’ APPLICATION  PRATIQUE  ET  L’EFFICACITE  DE  LA  VAPEUR 

COMME  DESINFECTANT. 

DIE  GESCHICHTE,  PRAKTISCHE  ANWENDUNG  UND  WIRKSAMKEIT  DES  DAMPFES  ALS 

DESINFEKTIONSMITTEL. 

BY  A.  N.  BELL,  A.M.,  M.D., 

Of  Brooklyn,  N.  Y. 

The  occurrence  aucl  attending  circumstances  of  my  first  knowledge  of  the  practical 
application  of  steam  as  a disinfectant  have  been  already  published,  but  under  such 
limitations  as  to  abundantly  justify  the  following  synopsis  in  connection  with  more 
recent  observations. 

While  I was  an  assistant  surgeon  in  the  Navy,  and  in  service  in  the  Gulf  Squadron 
during  the  epidemic  of  yellow  fever  which  prevailed  there  during  the  summer  and 
autumn  of  1847,  the  United  States  steamer  “ Vixen  ” was  one  of  the  earliest  infected 
vessels  of  the  fleet.  Being  of  small  draft  she  had  been  chiefly  confined  to  the  coast 
and  river  service  in  the  war  with  Mexico,  and  was,  consequently,  filthy  and  infested 


566 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


with  cockroaches  and  other  vermin.  I first  joined  the  “ Vixen”  in  December  of  that 

year. 

During  the  season  of  the  “ northers  ” there  was  a cessation  of  yellow  fever,  though 
there  was  a continuous  large  sick  list  composed  of  tedious  convalescents  and  frequently 
recurring  febrile  complaints.  On  the  return  of  hot  weather  in  the  following  May 
(1848),  and  in  anticipation  of  an  early  recurrence  of  yellow  fever  in  our  then  condi- 
tion, it  became  expedient  to  break  out  as  far  as  practicable  while  in  service,  and  paint 
ship.  Preliminary  to  this  proceeding,  on  the  suggestion  of  the  commander,  the  late 
Jas.  E.  Ward,  Esq.,  a final  effort  was  determined  upon  to  destroy  the  vermin  with 
steam.  Everything  thought  to  be  susceptible  of  injury  by  its  use  was  taken  on  deck, 
the  hatchways  were  carefully  closed  and  covered  with  tarpaulins,  with  opening  for  the 
passage  of  a leather  hose  only,  connected  with  the  steam-cock  of  the  boiler.  Steam  was 
turned  on  and  continuously  poured  in  below  decks  for  about  two  hours,  until  the 
leather  hose  in  immediate  connection  with  the  coupling  could  be  no  longer  maintained. 
On  removing  the  hatch  coverings  there  was  a forcible  gush  of  steam,  but  not  scalding 
hot,  and  the  first  surprising  effect  noticeable  on  going  below  was  the  complete  dryness 
of  all  the  exposed  surfaces;  not  a particle  of  moisture  remained.  Some  of  the  thinner 
bulkheads  were  cracked,  and  the  paint  on  them  generally  blistered ; and  the  lower  deck 
was  covered  with  dead  cockroaches,  all , apparently,  driven  from  their  hiding  places  to 
die  in  the  “country.”  The  steam  had  driven  them  from  their  inmost  recesses — had 
penetrated  every  crevice.  Having  no  registering  thermometers,  these  were  the  only 
evidences  of  high  temperature.  After  this  there  was  a thorough  scraping  and  painting 
and  an  abundant  use  of  whitewash  on  all  rough  surfaces,  both  above  and  below  decks. 
From  this  time  forward  to  the  end  of  the  cruise  there  was  a decided  improvement  in 
the  health  of  the  crew — no  more  fever  cases  occurred ; indeed,  so  complete  was  the 
change  in  the  health  of  the  crew  (of  about  sixty),  three  weeks  subsequently,  that  there 
was  no  sick  list.  The  inference  was  manifest. 

About  one  month  subsequent  to  the  steaming  of  the  “Vixen,”  the  gunboat  “Ma- 
hones,  ” Lieutenant  Commander  Wm,  D.  Porter,  returned  from  a surveying  expedi- 
tion up  the  Tuxpan  river,  and  made  signal  for  my  services.  (I  was  the  only  medical 
officer  at  the  time  attached  to  a gunboat  squad  off  the  mouth  of  the  Tuxpan  river.) 
There  I found  three  cases  of  yellow  fever,  and  within  a few  days  four  additional,  out  of 
a crew  of  eighteen.  The  “Mahones”  was  a vessel  captured  from  the  Mexicans,  had 
never  been  off  the  coast,  was  old  and  in  rotting  condition,  and  evidently  had  never 
been  cleansed  from  the  time  she  was  launched ; she  was  filthy  in  the  extreme,  and,  like 
the  “Vixen,”  was,  before  steaming,  infested  with  vermin.  The  salutary  effect  of  the 
steaming  of  the  “ Vixen  ” was  so  apparent  that  I at  once  advised  it  forthe  “ Mahones,” 
and  it  was  forthwith  applied  by  bringing  her  alongside,  and  by  means  of  the  1 ‘ Vixen’s  ’ ’ 
engine,  steam  was  injected  and  kept  up  for  about  two  hours;  and,  as  in  the  first  case, 
vermin  and  fever  were  both  destroyed. 

These  vessels  continued  in  service  in  the  vicinity  of  Vera  Cruz  until  early  in  the 
following  July,  when  they  proceeded  to  Norfolk,  Va.,  where  they  arrived  in  the  height 
of  hot  weather.  After  three  weeks,  the  “Vixen”  was  transferred  to  Coast  Survey 
Service  in  the  Chesapeake  Bay  for  the  remainder  of  the  summer.  The  “Mahones” 
was  found  to  be  unseaworthy  ; she  was  laid  up  at  the  Portsmouth  Navy  Yard  during 
the  summer,  and  subsequently  sold  and  broken  up  as  refuse.  In  neither  of  these  ves- 
sels was  there  any  return  of  the  fever  subsequent  to  having  been  steamed. 

About  the  same  time  that  the  “ Vixen  ” and  “ Mahones  ” arrived  at  Norfolk,  the 
Frigate  “Cumberland”  and  the  Steamer  “Scorpion,”  arrived  at  New  York.  The 
“Scorpion”  was  at  once  put  in  quarantine,  on  account  of  recent  cases  of  yellow  fever 
on  board  ; and  the  “ Cumberland  ” not  having  had  any  cases  since  the  previous  sum- 
mer, was,  after  a few  days’  detention,  permitted  to  go  up  to  the  Navy  Yard,  but  at  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  567 


very  beginning  of  the  work  of  “breaking  out  ” and  the  exposure  of  new  hands,  yellow 
fever  appeared  ; she  was  placed  in  quarantine,  and  there  kept  until  November  follow- 
ing. 

The  “ Cumberland  ” and  “Scorpion  ” were  of  the  same  squadron  as  the  “ Vixen” 
and  “Mahoues,”  hut  were  more  commodious,  better  ventilated,  more  easily  kept  in 
cleanly  condition  and,  apparently,  in  every  respect  in  a more  healthful  condition  than 
either  the  “Vixen”  or  “Mali  ones,”  except  that  they  had  not  been  steamed. 

The  next  application  of  this  knowledge  with  which  I am  acquainted  was  by  the  late 
Elisha  Harris,  m.d.,  at  the  time  of  his  death  Secretary  of  the  State  Board  of  Health  of 
New  York,  whose  active  cooperation  I had  in  the  care  of  yellow  fever  patients  at  Bay 
Ridge  and  at  Fort  Hamilton,  in  1856,  and  who  was  at  the  time  Physician  in  Chief  of 
the  Quarant  ine  Hospital.  He  had  occasion  to  observe  the  danger  of  yellow  fever  to  the 
women  who  washed  the  clothing  from  hospital  patients  and  ififected  vessels  in  the 
ordinary  way.  I had  related  to  him  my  observations  on  the  use  of  steam  and  sug- 
gested its  adoption.  Under  his  direction  steam  tubs  for  boiling,  and  a steam-heated 
chamber  for  drying  the  clothing  were  introduced,  with  the  result  of  wholly  preventing 
any  further  recurrence  of  the  disease  among  the  washerwomen. 

Again  in  1859,  after  the  quarantine  structures  on  Staten  Island  had  been  destroyed, 
and  the  practice  of  burning  all  clothiug,  bedding  etc.,  from  infected  vessels,  in  an  iron 
scow  in  the  opeu  bay,  by  the  direction  of  the  Health  Officer  at  that  time,  a “ floating 
hospital”  was  provided,  consisting  of  the  hulk  of  an  old  steamboat  without  fitting, 
anchored  in  the  lower  bay  awaiting  the  arrival  of  patients.  Fortunately,  Dr.  Harris 
was  placed  in  charge.  Proper  protection  of  the  washerwomen  and  other  employes  was 
his  first  consideration.  A copper  steam  generator,  capacious  steam  vats  and  wash- 
tubs  were  erected  on  the  projecting  framework  of  one  of  the  side  wheels.  Into  the  vats 
every  infected  article  of  clothing  and  all  hospital  bedding  worth  preserving  were 
thrown.  All  articles  from  infected  vessels  were  received  directly  from  the  boats  into 
the  steam  chamber,  without  exposing  the  hospital  ship  or  any  of  its  inmates  to  the 
danger  of  contact.  And  from  the  hospital  wards,  every  article  of  soiled  clothing  or  bed- 
ding, as  soon  as  soiled,  was  at  once  removed  and  thrown  into  the  steam  vats,  and  there 
immediately  subjected  to  the  highest  degree  of  steam  heat  of  which  the  apparatus  was 
capable.*  Successors  to  Dr.  Harris  in  the  same  service,  myself  among  the  number, 
practiced  the  same  means  for  fourteen  years,  1856  to  1869,  during  the  whole  period  from 
the  time  it  was  first  introduced  to  the  time  when  the  floating  hospital  for  the  care  of 
infectious  diseases  in  the  lower  bay  of  New  York  was  discontinued  ; and,  so  far  as  I 
have  been  able  to  learn,  without  the  communication  of  a single  case  of  infectious  dis- 
ease to  any  inmate.  Among  the  first  acts  of  my  official  connection  with  the  New  York 
Quarantine,  in  1870,  was  to  have  constructed  a steam  disinfecting  chamber  and  vat,  in 
connection  with  the  Hospital. 

While  myself  in  charge  of  the  Fjoating  Hospital,  during  the  first  summer  of  the 
War,  1862,  of  all  the  infected  vessels  that  arrived  at  the  Port  of  New  York,  the  Quar- 
termaster’s Steamer  “Delaware”  was  probably  the  worst;  at  auy  rate,  the  malig- 
nancy of  the  fever  from  that  vessel  was  greater  than  that  from  any  other.  The  “ Dela- 
ware ’ ’ had  proceeded  from  the  Tortugas  in  the  early  part  of  August,  with  invalid  sol- 
diers on  board,  stopped  at  Key  West,  Fernandina,  St.  Augustine  and  Port  Royal,  where, 
in  consequence  of  having  yellow  fever  on  board,  she  was  kept  in  quarantine  twelve 
days,  and  then  sent  to  New  York.  She  arrived  there  September  21st,  having  lost  one 
man  with  the  fever  on  the  passage  from  Port  Royal.  On  arrival,  her  Commander,  Cap- 
tain James  S.  Cannon,  and  two  of  the  crew  were  sent  to  the  floating  hospital,  and  with- 
in five  days  afterward  seven  of  the  invalid  soldiers,  all  well  marked  cases  of  yellow 


* Fourth  National  Quarantine  and  Sanitary  Convention,  Boston,  1S60,  p.  224. 


568 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


fever,  and  some  of  them  so  malignant  as  to  have  black  vomit  supervene  within  a few 
hours  from  the  time  of  attack  and  to  die  within  forty-eight  hours.  One  died  on  hoard 
the  “Delaware”  within  24  hours,  his  case  being  so  malignant  that  the  boarding  offi- 
cer deemed  it  useless  to  transfer  him.  In  this  state  of  affairs,  at  my  urgent  request, 
the  remainder  of  the  invalid  soldiers  (18),  were  transferred  to  the  (yellow  fever)  float- 
ing hospital,  for  safety.  They  all  escaped  the  disease  ; and  I have  not  the  least  doubt 
that  if  all  the  soldiers  had  been  removed  immediately  on  arrival,  several  lives  might 
have  been  saved  instead  of  lost  by  depending  upon  the  effects  of  “ fumigation.  ” During 
the  convalescence  of  Captain  Cannon,  I' recommended  to  him  the  use  of  steam  for  the 
purpose  of  effectually  disinfecting  his  vessel.  I subsequently  received  the  following 
letter  : — 

U.  S.  Transport  “ Delaware,”  New  York,  November  30th,  1862. 

Dr.  Bell: — 

Dear  Sir — During  my  confinement  in  Quarantine  Hospital  with  yellow  fever,  last  summer, 
you  suggested  the  idea  of  disinfecting  my  vessel  by  steam.  In  accordance  with  the  suggestion, 
before  my  recovery  the  engineer  steamed  the  lower  cabin,  where  nearly  all  the  sick  had  been  con- 
fined. After  my  recovery  I more  effectually  steamed  the  vessel  by  closing  her  up  below  and 
driving  the  steam  through  her  lower  holfl  and  bilges.  This  I did  by  attaching  a hose  to  the 
boiler  and  leading  it  below  through  an  aperture  left  for  that  purpose.  Although  we  remained 
in  quarantine  three  weeks  after  the  first  steaming,  we  had  no  sickness  among  a crew  of  twenty 
persons ; and  since  that  time  the  steamer  “ Delaware  ” has  been  in  a perfectly  healthy  state. 
After  refitting,  the  “Delaware”  was  sent  to  Port  Royal  with  soldiers  and  encountered  a heavy 
gale ; of  course  everything  was  damp,  but  no  sickness  occurred  on  board  and  the  troops  remained 
perfectly  healthy  after  landing.  On  my  return,  over  a hundred  invalid  soldiers  came  North 
with  me,  but  there  was  no  sickness  among  them  except  that  which  they  brought  from  the  hospi- 
tals. The  only  injury  resulting  from  the  use  of  the  steam  was  to  the  paint,  which  it  stained; 
and,  the  first  time  charring  the  leather,  and  the  second  time  melting  the  rubber  hose.  In  using 
steam,  hose  which  cannot  be  affected  by  heat  easily  ought  to  be  provided  especially  for  the  pur- 
pose, by  a copper  coupling  about  ten  feet  long  attached  to  the  cock  where  the  steam  comes  directly 
from  the  boiler,  and  the  heat  is  most  intense.  Much  injury  might  otherwise  result  from  the 
cracking  of  the  hose,  if  leather,  or  melting  it,  if  rubber,  by  the  escape  of  steam. 

I am  so  well  satisfied  of  the  beneficial  effects  of  steam  on  shipboard,  that  I would  be  sure  of 
clearing  my  vessel  of  that  dread  disease,  the  yellow  fever,  by  its  use,  in  a very  short  time. 

I am  very  respectfully,  your  obedient  servant, 

James  S.  Cannon, 

Master  U.  S.  Transport  “ Delaware.”* 

In  reporting  my  experience  of  that  year,  1862,  to  the  Medical  Society  of  the  State 
of  New  York,  I formulated  at  the  time,  among  others,  the  following  conclusions: — 

2.  That  inasmuch  as  a temperature  of  145°  Fahrenheit,  which  coagulates  albumen, 

effectually  disinfects  the  worst  fomites,  we  have  in  this  fact  alone 

strong  evidence  of  the  identity  of  virus  with  organic  matter. 

3.  That  the  necessary  degree  of  heat  for  disinfection  may  he  applied  in  some  form 
to  almost  every  article  of  commerce  or  apparel  liable  to  the  virus  of  infection  or  con- 
tagion, without  injury. 

4.  That  the  examples  furnished  are  an  amply  sufficient  guide  for  the  application  of 
heat  under  the  most  variable  circumstances. 

During  the  excitement  attendant  on  the  retention  of  persons  on  board  cholera 
infected  ships  in  the  lower  bay  of  New  York,  in  the  month  of  June,  1866,  I was  invited 
by  Dr.  John  Swinburne,  health  officer  of  the  port,  to  institute  certain  experiments  at 
Seguin’s  Point,  Staten  Island,  for  the  purpose  of  demonstrating  to  him  the  applicabil- 
ity and  utility  of  steam  to  infected  clothing  and  vessels.  The  means  at  command  con- 


* Transactions  of  tbo  Medical  Society  of  the  Stato  of  New  York,  1864. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  569 


sisted  of  a small  engine,  so  nearly  worn  out  as  to  be  incapable  of  sustaining  a pressure 
of  more  than  thirty  pounds,  and  which,  starting  at  this  pressure,  could  keep  up  steam 
for  only  ten  minutes  at  a time  ! However,  after  considerable  hesitation,  the  experi- 
ments were  undertaken.  A coiled  pipe,  of  356  feet  in  extreme  length,  was  connected 
with  the  steam  pipe  of  the  engine,  and  around  it  a furnace  chamber  of  ordinary 
cellar  size,  bricked  up,  to  superheat  the  steam  escaping  from  the  engine.  Over  this 
furnace,  with  the  pipe  communicating,  a chamber  of  500  cubic  feet  capacity  was 
constructed. 

This  chamber  was  formed  in  the  jamb  of  an  old  factory  chimney,  two  sides  of  brick; 
the  other  two  sides,  roof  and  floor  of  uuplaued  pine  boards.  Although  this  chamber 
was  far  from  being  air  tight,  an  openiug  was  made  ou  one  side  into  the  chimney  flue, 
covered  hy  a trap  door  to  which  a string  was  fastened  and  leading  to  the  outside,  so  as 
to  provide  for  the  escape  of  air  on  first  letting  in  steam,  and  to  admit  of  closure  at  will. 
Thus  provided,  three  thermometers  were  placed  : one,  a registering,  midway  from  the 
floor  to  the  roof,  suspended  on  a pine  board  six  inches  from  the  back  wall  ; a second 
penetrated  near  the  top,  and  a third  near  the  floor — both  being  bent  tubes  with  free 
bulbs  in  the  chamber  and  scales  outside.  In  the  chamber  were  placed  two  basins  of 
water  of  two  quarts  each,  one  on  the  floor,  and  the  other  on  a bench  nearly  midway, 
from  floor  to  roof — in  the  centre  of  the  room;  a few  clams,  oysters,  eggs,  and  small  fish; 
also  a pair  of  linen  pantaloons,  and  a shirt  nicely  done  up.  The  initial  temperature  of 
the  water  in  the  hasins  was  75°  and  of  the  room  80°.  Some  of  the  clams,  eggs  and 
oysters  were  wrapped  with  several  folds  of  wet  blanket,  others  with  dry;  and  others 
were  left  free,  in  different  parts  of  the  room.  Thus  arranged,  with  a good  fire  in  the 
furnace  under  the  pipe,  and  the  boiler  of  the  engine  under  a pressure  of  thirty  pounds, 
steam  was  turned  into  the  chamber  and  allowed  to  escape  from  the  engine  slowly,  till 
the  head  of  steam  was  exhausted,  which  occupied  ten  minutes.  At  the  end  of  this 
time,  the  door  was  opened,  and  in  two  minutes,  the  chamber  entered.  The  thermom- 
eters meanwhile,  having  run  up,  the  one  at  the  top  of  the  chamber,  to  224°;  the  one 
at  the  bottom,  205°,  and  the  self-registering  stood  at  210°.  On  first  opening  the  cham- 
ber the  floor  was  quite  wet,  but  it  was  so  hot  that  in  less  than  ten  minutes  the  mois- 
ture had  all  evaporated.  The  water  in  the  basin  on  the  floor  was  heated  to  162°.  Ou 
the  bench,  150°.  The  fish,  eggs,  oysters  and  clams,  that  were  not  enveloped,  were  all 
well  cooked.  Those  that  were  wrapped  in  the  blanket,  both  wet  and  dry,  were  only 
partially  cooked— and  about  equally.  The  clothing  was  perfectly  dry  and  stiff,  and  in 
every  respect  in  as  good  condition  as  when  it  was  placed  in  the  chamber.  It  was  only 
very  hot. 

The  experiment  was  repeated,  and  the  temperature  taken  every  minute,  as  follows: 


Time. 

Pressure 
of  Steam 
Pounds. 

Upper 

Therm. 

Degrees. 

Lower 

Therm. 

Degrees. 

Self-regis. 

Therm. 

Degrees. 

Initial 

30 

96 

112 

95 

1st  minute  ... 

27 

160 

135 

2d  “ .... 

24 

176 

165 

3d  “ .... 

22 

186 

180 

4th  “ .... 

16 

192 

190 

5th  “ .... 

15 

199 

195 

6th  “ .... 

14 

212 

198 

7th  “ .... 

13 

217 

201 

8th  “ .... 

10 

220 

202 

9th  “ .... 

10 

222 

204 

10th  “ .... 

10 

224 

205 

210 

570 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  experiment  was  several  times  repeated,  sometimes  covering  a period  of  five 
minutes  only,  and  at  others,  as  in  the  foregoing,  ten  minutes,  which  is  a fair  example 
of  the  result. 

July  9th,  1886.  Having  obtained  the  temporary  use  of  a Metropolitan  fire  engine, 
capable  of  sustaining  a steam  pressure  of  100  pounds,  and  having  the  privilege  of  using 
a room  that  had  been  used  as  a dog  kennel,  adjoining  the  engine  house  on  Centre  street, 
New  York,  the  following  experiments  were  made  : The  cubic  capacity  of  the  room 
was  4240  feet,  and  over  the  floor  Was  an  accumulation  of  not  less  than  a cart-load  of 
straw  rubbish,  saturated  with  moist  dog  filth,  offeusive  in  the  extreme.  At  each  end  of 
the  room  were  large  folding  doors,  about  twelve  feet  square,  the  back  ones,  being  half 
glass,  presenting  a large  radiating  surface.  Around  the  doors  were  large  crevices,  in  some 
places  of  more  than  an  inch  in  width.  Horse  blankets  were  hung  over  the  worst  places, 
however,  and  thermometers  placed,  one  three  feet  from  the  floor,  projecting  a foot  from 
the  side  of  the  room;  one  near  the  top  and  centre;  one  self- registering,  free,  and  three 
feet  from  the  floor;  and  one  self- registering,  wrapped  in  eight  folds  of  heavy  horse 
blanket,  laid  on  the  floor.  Half  an  ounce  of  liquefied  carbolic  acid  was  added  to  the 
water  in  the  boiler.  The  following  is  the  table  of  observations  : — 


Time. 

Steam 

Press. 

Pounds. 

Lower 

Thr. 

Degrees. 

Up.  Ther. 
Degrees. 

Free 

Self-reg. 

Ther. 

Degrees. 

Env.  Self- 
reg.  Thr. 
Degrees. 

Initial,  4.30.... 

160 

80 

80 

4.35..., 

60 

147 

140 

• •• 

4.40.... 

40 

145 

144 

... 

4.45.... 

45 

138 

138 

... 

4.50.... 

65 

138 

140 

... 

4.55.... 

100 

138 

142 

... 

5.00.... 

120 

138 

144 

5.05.... 

160 

138 

140 

. . . 

5.10.... 

120 

153 

158 

5.15.... 

75 

162 

152 

5.20.... 

90 

158 

146 

... 

5.25.... 

90 

147 

158 

... 

5.30.... 

100 

166 

162 

... 

5.35.... 

90 

170 

166 

. .. 

5.40.... 

120 

166 

158 

... 

5.45.... 

145 

166 

170 

... 

5.50.... 

80 

186 

176 

5.55.... 

40 

191 

178 

177 

155 

On  throwing  open  the  doors  the  room  was  entered  immediately,  and  when  the  steam 
had  sufficiently  cleared  away  to  see,  in  four  or  five  minutes,  the  floor  alone  was  wet  (as 
it  was  before  the  beginning  of  the  experiment),  the  side  walls  and  ceiling  perfectly 
dry.  It  may  be  here  remarked  that  the  room  was  ceiled  up  with  painted  pine  boards, 
from  the  floor,  four  feet  high;  the  remainder  plastered  wall.  The  paint  on  the  wood 
was  blistered,  and  the  resin  was  running  from  the  pine  knots.  There  was  no  disagree- 
able odor  whatever  in  the  room,  and  but  a very  faint  odor  of  carbolic  acid.  The  filth, 
now  rendered  inoffensive,  was  removed. 

A second  experiment,  with  the  same  appurtenances  and  a super-heating  coil  of  pipe 
attached,  as  in  previous  experiment,  was  made  on  the  next  day.  In  ten  minutes’  time 
the  temperature  was  raised  to  160°,  and  kept  steadily  above  that,  gradually  rising  to 
the  close,  at  the  end  of  an  hour,  at  which  time  the  lower  thermometer  was  at  186°,  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


571 


upper  one,  180°;  the  free  self-registering,  188°  and  the  enveloped  one  190°.  The  same 
could  have  heen  maintained  indefinitely. 

A third  experiment  with  the  same  appurtenances  obtained  in  the  same  length  of 
time  the  temperature  of  lower  thermometer  190°,  upper  200°;  self-registering,  wrapped 
in  sixteen  folds  of  heavy,  dry  horse  blanket,  190°;  do.  in  sixteen  folds,  wet,  175°. 

A fourth  experiment  gave  nearly  the  same  results.  The  record  made  at  the  time 
states  that  the  only  apparent  benefit  of  the  superheater  in  these  experiments,  over  wet 
steam,  consists  in  the  maintenance  of  a more  steady  high  temperature  and  greater  pene 
trahility  of  the  heat  into  clothing. 

In  whatever  degree  these  experiments,  in  the  aggregate,  may  appear  unfavorable,  it 
is  scarcely  necessary  to  again  allude  to  the  imperfection  of  the  appurtenances  in  order 
to  account  for  it.  It  will  suffice  to  state  that  the  appurtenances  were  accepted  with  all 
of  their  imperfections,  because  of  the  experimenter’s  wish  to  show  the  adaptability  of 
steam  as  a disinfectant,  even  under  the  most  unfavorable  circumstances.  And  further, 
that  almost  any  degree  of  temperature  can  be  obtained  to  satisfy  the  skeptical  that  it 
may  be  high  enough  to  destroy  all  organic  matter  of  whatsoever  nature,  though  the 
facts  before  adduced  conclusively  show  that  the  temperature  of  wet  steam  kept  for  two 
or  three  hours,  has,  in  yellow  fever,  at  least,  proved  to  be  sufficient  for  the  complete 
and  speedy  disinfection  of  a ship.  With  an  engine  equal  to  the  fire  engine  used  in 
these  last  experiments,  or  such  as  those  commonly  used  in  the  tug-boats  in  the  harbor 
of  New  York,  the  writer  has  no  question  whatever,  that  in  three  hours’  time  a sufficient 
degree  of  steam  heat  can  be  thrown  into  any  room  or  ship  to  disinfect  it  of  yellow 
fever,  and,  a fortiori,  all  other  infections. 

The  next  practical  illustration  was  the  following,  furnished  me  by  the  Secretary  of 
the  Navy  : — 

Copy  of  the  official  report  of  Commander  Chandler,  of  the  U.  S.  Steamer  “Don,” 
on  the  disinfection  of  his  vessel  by  steam. 

U.  S.  Steamer  “ Don  ” (4th  Rate),  Santa  Cruz,  W.  I.,  December  16th,  1867. 
Hon.  Gideon  Welles,  Secretary  of  the  Navy  : — 

Si) — I have  the  honor  to  inform  the  Department  that  yellow  fever  broke  out  on  board  this 
vessel  on  the  16th  of  November,  in  its  most  virulent  form.  Seven  men  were  taken  down,  but  the 
symptoms  did  not  at  first  seem  alarming,  and  the  fever  was  light.  Soon,  however,  delirium  took 
place,  followed  in  a few  hours  by  black  vomit  and  death.  I was,  by  order  of  Rear-Admiral 
Palmer,  examining  the  Island  of  St.  John’s,  as  reports  had  been  circulated  that  the  recent  earth- 
quake had  destroyed  a portion  of  it.  These  reports  were  groundless.  I immediately  returned  to 
St.  Thomas,  when  the  fever  became  malignant,  and  was  ordered  to  Santa  Cruz.  On  arriving  here 
the  ship  was  anchored  with  a spring,  and  was  always  broadside  to  the  wind.  The  sick  were  at 
once  landed,  Commodore  Bissell  kindly  sending  his  launch  for  that  purpose,  and  clothing  and 
bedding  aired.  Some  time  ago  one  of  the  members  of  the  Board  of  Health  of  the  City  of  New 
York  gave  me  tho  pamphlet  which  I have  the  honor  to  enclose,  in  relation  to  overcoming  miasma 
by  heat  or  steam,  and  I resolved  at  once  to  test  it.  The  ship  was  thoroughly  impregnated  with 
yellow  fever.  I caused  the  hatches  of  the  berth  deck  and  ward  room  to  be  securely  closed  and 
battened  down.  One  joint  of  the  steam  heater  on  the  berth  deck  was  disconnected,  and  the  same 
operation  performed  in  the  ward  room.  A thermometer  was  lowered  through  a small  slit  in  the 
tarpaulin,  and  after  two  hours’  steaming  in  the  ward  room  it  indicated  205°,  and  on  the  berth 
deck  172°.  I ain  under  the  impression  that  the  true  temperature  was  at  least  10°  above  these 
figures,  as  the  act  of  bringing  tho  thermometer  in  contact  with  tho  air  above  caused  it  to  fall  too 
quickly  for  an  accurate  observation.  The  hatches  were  then  opened,  decks  dried  down,  the  joints 
of  steam  heaters  replaced,  and  steam  turned  through  the  heaters,  and  in  two  hours  there  was  no 
indication  of  the  extreme  heat  those  places  had  been  exposed  to,  except  blistered  paint,  and  a few 
articles  of  furniture  that  were  glued  together  had  fallen  apart.  The  berth  deck  had  previously 
been  scraped,  ready  for  a new  coat  of  whitewash,  which  was  soon  put  on,  and  it  affords  us  much 


572 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


happiness  to  state  that  no  new  cases  of  fever  occurred.  Several  men  afterward  complained  of 
pains  in  the  head  and  back,  with  a little  fever,  showing  that,  although  the  heat  had  mortally 
affected  the  disease,  yet  it  was  still  struggling  for  existence.  We  had  twenty-three  cases  on  board, 
and  seven  died.  I have  the  honor  to  inform  the  Department  that  I am  fully  persuaded  that  heat 
eradicated  the  disease  on  board  this  vessel  as  effectually  as  a severe  frost  could  have  done,  and  I 
would  respectfully  recommend  that  vessels  of  war  destined  to  cruise  on  the  West  India  station  be 
provided  with  means  of  steaming  the  lower  decks  and  holds. 

The  medical  officer,  A.  A.  Surgeon  Thomas  Owens,  has  made  a detailed  report  to  the  Bureau 
of  Medicine  and  Surgery.  The  fire  department,  as  usual,  suffered  most,  owing,  I think,  to  im- 
prudent exposure  in  coming  from  the  hot  fire-room  to  a cool  draft  on  deck,  and  also  from  exces- 
sive drinking  of  cold  water  while  in  a heated  state.  This  is  the  third  yellow  fever  ship  that  I 
have  served  on  board  of,  but  I have  never  before  seen  the  disease  in  so  violent  a form. 

Very  respectfully,  your  obedient  servant, 

(Signed)  R.  Chandler,  Commander  U.  S.  Navy.* 

Besides  the  examples  above  given  there  have  been  several  other  instances  of  the 
application  of  steam  to  American  men-of-war,  for  the  purpose  of  disinfection,  but  so 
imperfectly,  or  in  conjunction  with  other  means  to  such  an  extent,  as  to  divest  steam 
of  the  credit  it  deserves. 

Sanitarians,  as  other  persons  who  have  not  observed  the  proper  application  of  steam 
under  such  circumstances,  are  loath  to  accept  it,  on  the  false  assumption  that  it  will 
cover  the  surrounding  walls  and  saturate  everything  into  which  it  is  forced  with  mois- 
ture, a fallacy  which  actual  observation  wholly  dispels.  On  the  contrary,  steam  under 
pressure , it  should  he  borne  in  mind,  is  always  above  that  given  off  from  the  surface 
of  boiling  water,  and  when  properly  applied,  it  so  quickly  and  effectually  heats  what- 
ever substances  with  which  it  comes  in  contact  as  to  render  them  repellant  of  moisture 
and  adjuvants  in  its  dissipation  ; an  excess  of  moisture  on  the  surface,  or  even  in  the 
substance  of  things,  such  as  baled  rags,  to  which  it  has  been  applied,  is  an  indication 
of  insufficiency  of  temperature.  Under  20  lbs.  pressure  the  temperature  of  steam  is 
230°  F. ; under  25  lbs. , 240°  F. ; and  under  30  lbs. , 250°  F.  The  lowest  of  these  tem- 
peratures is  found  to  be  sufficient  to  destroy  the  most  resistant  spores  in  twenty  minutes; 
while  the  highest  is  effective  almost  immediately.  But  to  practically  apply  the  requi- 
site temperature,  the  nature  of  the  fomites,  the  space  and  the  character  of  the  surround- 
ings, all  have  to  be  taken  into  consideration. 

Heat  has  long  been  known  to  be  the  most  powerful  of  all  disinfectants,  but  since  the 
general  belief  in  the  germ  origin  of  infectious  diseases,  the  desideratum  has  been — how 
to  apply  it  with  a sufficient  degree  of  intensity  to  destroy  the  germs,  without  at  the 
same  time  destroying,  or  at  least  injuring,  the  material  infested  by  them  : because  bi- 
ologists have  been  wont  to  teach — what  many  sanitarians  have  erroneously  believed  — 
that  the  only  safe  test  was  the  resisting  power  of  certain  organisms  found  in  boiling 
springs  and  under  other  circumstances,  with  no  known  relation  to  disease  germs  or  the 
eontagium  of  disease  under  any  circumstances  whatsoever.  The  impracticability  of  this 
effort  has  finally  had  the  effect  of  diverting  the  attention  of  biologists  from  dry  heat  to 
the  effect  of  steam  on  disease  germs,  and  they  have  recently  discovered  the  correctness 
of  that  for  which  I have  contended  for  twenty-five  years,  and  practically  demonstrated 
in  the  manner  above  described,  nearly  thirty  years  ago,  that  “ a temperature  of  145°  F. 
effectually  disinfects  the  worst  fomites.” 

George  M.  Sternberg,  m.d.,  Major  and  Surgeon,  U.  S.  Army,  in  a contribution  to 
the  American  Journal  of  Medical  Sciences  for  July,  1887,  p.  146,  cites  the  conclusions 
of  Koch  and  Wolff  hugel  on  the  effects  of  dry  heat,  as  follows  : — 


* Transactions  of  the  Medical  Society  of  the  State  of  New  York,  1868,  p.  91. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


573 


1.  A temperature  of  100°  C.  (212°  F. ),  maintained  for  one  hour  and  a half,  will  de- 
stroy bacteria  which  do  not  contain  spores. 

2.  Spores  of  mould-fungi  require  for  their  destruction  in  hot  air  a temperature  of 
from  110-115°  C.  (230-239  F.),  maintained  for  one  hour  and  a half. 

3.  Bacillus  spores  require  for  their  destruction  in  hot  air  a temperature  of  140°  C. 
(284°  F. ),  maintained  for  three  hours. 

He  then  proceeds  to  relate  the  results  of  his  own  experiments  with  moist  heat  on  the 
lacilli  of  typhoid  fever,  cholera,  swine  plague,  tuberculosis  and  on  numerous  other 
microorganisms.  His  conclusions  are,  that — 

“The  temperature  required  to  destroy  the  vitality  of  pathogenic  organisms  varies 
for  different  organisms. 

“ In  the  absence  of  spores,  the  limits  of  variations  are  about  18°  F. 

“A  temperature  of  132.8°  F.  is  fatal  to  the  bacillus  of  anthrax,  the  bacillus  of 
typhoid  fever,  the  bacillus  of  glanders,  the  spirillum  of  Asiatic  cholera,  the  erysipelas 
coccus,  to  the  virus  of  vaccinia,  of  rinderpest,  of  sheep-pox,  and  probably  of  several 
other  infectious  diseases. 

“A  temperature  of  143.6°  F.  is  fatal  to  all  of  the  pathogenic  or  non-pathogenic 
organisms  tested,  in  the  absence  of  spores  (with  the  single  exception  of  sarcina  lutea, 
which,  in  one  experiment,  grew  after  exposure  to  this  temperature). 

“A  temperature  of  212°  F.  maintained  for  five  minutes  destroys  the  spores  of  all 
pathogenic  organisms  tested. 

“It  is  probable  that  some  of  the  bacilli  which  are  destroyed  by  a temperature  of 
140°  F.  form  endogenous  spores,  which  are  also  destroyed  at  this  temperature.” 

It  is  important  to  notice  in  this  connection  that,  according  to  the  same  writer,  “ the 
cholera  germ  of  Koch  does  not  form  spores,  and  there  is  good  reason  to  believe  that  the 
same  is  true  as  regards  the  germs  of  yellow  fever,  of  scarlet  fever,  and  of  smallpox, 
which  have  not  yet  been  demonstrated.  This  inference  is  based  upon  evidence  obtained 
in  the  practical  use  of  disinfectants,  and  upon  certain  facts  relating  to  the  propagation 
of  these  diseases.”  * 

Dr.  Parsons,  in  his  “ Report  to  the  Local  Government  Board,”  London,  April  27th, 
1887 , remarks  that — 

* ‘ The  disinfection  of  rags  by  heat  otherwise  than  by  boiling  requires  special  apparatus. 
Dry  heat  penetrates  so  slowly  into  non-conducting  materials,  such  as  rags,  that  it  is 
impracticable  to  disinfect  them  in  the  bale  by  this  agency  in  any  reasonable  time, 
unless,  perhaps,  with  the  aid  of  currents  of  hot  air  or  exhaust  apparatus. 

‘ ‘ A machine  for  the  preliminary  disinfection  of  woolen  rags  has  been  patented  by 
Mr.  Illingworth,  rag-flock  manufacturer,  of  Batley.  It  consists  of  a cylindrical  cage 
revolving  within  an  iron  steam-jacketed  cylinder,  closed  at  the  end  by  a door.  The  rags 
have  to  be  unpacked  from  the  bale,  and  are  placed  inside  the  cage,  where,  as  the  cage 
revolves,  they  are  caught  and  turned  over  by  projecting  prongs.  The  steam  in  the 
jacket  stands  at  seventy  pounds  pressure,  equal  to  a temperature  of316°  F.,  but  it  does 
not  ordinarily  enter  the  interior  of  the  cylinder.  The  action  of  the  heat  is,  however, 
supplemented  by  the  fumes  of  burning  sulphur.  A charge  of  rags  is  1 cwt.  to  II  cwt., 
and  I found  that  one  and  a half  hour’s  exposure  was  necessary  in  order  to  raise  such 
charge  to  a temperature  of  217°  F.  By  the  introduction  of  a jet  of  steam  the  time 
necessary  to  attain  a like  temperature  was  shortened  to  thirty-five  minutes,  the  rags  not 
being  made  appreciably  damp  ; indeed,  they  had  lost  weight. 

“ A machine  has  also  been  invented  by  Mr.  Illingworth  for  the  disinfection  of  rags 
in  the  bale.  It  is  a steam-jacketed  chamber,  with  a tightly  fitting  door  ; the  cold 'air 


* “ Disinfection  and  Individual  Prophylaxis  against  Infectious  Diseases  ” (Lomb  Prize  Essay). 
By  George  M.  Sternberg,  m.p.,  Major  and  Surgeon,  U.  S.  Army,  p.  108. 


574 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


in  the  interstices  of  the  bale  being  displaced  by  exhausting  the  chamber  with  an  air 
pump,  and  replaced  by  chlorine  or  sulphurous  acid  gas,  let  in  by  opening  a valve.  The 
use  of  this  machine,  however,  appeared  to  have  been  abandoned. 

“ Some  experiments  on  bales  of  rags  made  in  Lyon’s  patent  disinfector  are  recorded 
in  my  report  on  ‘ Disinfection  by  Heat  ’ (Annual  Report  of  the  Medical  Officer  of  the 
Local  Government  Board,  1884).  This  apparatus  is  a steam-jacketed  chamber,  with  a 
tightly-fitting  door,  steam  being  admitted  both  into  the  jacket  and  into  the  interior. 
The  pressure  of  the  steam  in  the  jacket  is  kept  above  that  in  the  interior,  so  as  to  avoid 
condensation.  The  steam  in  the  interior  is  let  off  from  time  to  time,  and  re-applied,  so 
as  by  the  alternations  of  pressure  to  displace  the  cold  air  remaining  in  the  interstices. 

“ In  a bale  of  packed  cotton  rags  weighing  500  cwt.  a hole  was  bored  with  an  auger; 
into  this  a registering  thermometer  was  inserted  and  the  hole  plugged  with  a wooden 
plug.  The  hale  was  then  exposed  in  the  machine  for  four  hours,  to  steam  at  15  lbs. 
pressure,  relaxed  every  half  hour,  the  pressure  in  the  jacket  being  30  lbs.  At  the  end 
of  the  time  the  thermometer  was  found  to  register  252°  F.  The  bale  had  gained  in 
weight  27  lbs.  or  4.8  per  cent.  In  the  centre  of  a bale  of  woolen  rags  (not  press-packed) 
weighing  549  lbs.,  a temperature  of  255°  F.  was  by  similar  means  obtained  after  two 
hours,  the  increase  in  weight  through  condensation  of  moisture  being  25  lbs.  or  4.4  per 
cent.” 

This  last  and  a dozen  other  kinds  of  disinfecting  apparatus— including  that  of  Parker 
and  Blackman,  in  use  at  the  New  York  Quarantine,  with  which,  in  conjunction  with 
Dr.  William  M.  Smith,  Health  Officer  of  the  Port  of  New  York,  and,  in  part,  with  Dr. 
H.  M.  Biggs,  of  the  Carnegie  Laboratory,  New  York,  my  most  recent  experiments  and 
observations,  covering  a period  of  nearly  two  years,  have  been  conducted,  chiefly  in  the 
disinfection  of  baled  rags — meet  the  necessity  of  obtaining  the  requisite  degree  of  tem- 
perature throughout  the  bale  in  the  shortest  possible  time  without  causing  combustion 
of  the  rags. 

The  apparatus  is  erected  on  a floating  scow,  and  consists  of  an  ordinary  engine,  of 
sufficient  power  and  boiler  strength,  with  an  attached  superheater.  To  this  is  appended 
a series  of  iron  boxes  of  about  the  shape  of,  and  large  enough  to  admit,  a bale  of  rags 
pushed  in  endwise.  Each  one  of  several  boxes  has  penetrating  through,  from  the  rear 
end,  a gimlet-bit  screw,  or  several  such  screws,  nearly  as  long  as  a bale  of  rags,  enlarged 
from  a point  to  about  two  inches  in  diameter,  and  when  more  than  one  is  used,  at  such 
a distance  apart  as  to  about  equally  divide  the  end  of  a bale.  These  screws  are  hollow 
and  perforated  in  their  whole  circumference  and  length,  and  each  one  is  the  terminus  of 
a steam-escape  cock  to  which  it  is  coupled.  The  screws  are  rapidly  revolved  by  the 
machinery.  On  pushing  in  a bale  of  rags,  it  no  sooner  comes  in  contact  with  the  poiuts 
of  the  screw  or  screws  than  it  is  drawn  in  with  great  rapidity.  The  box  is  now  closed 
by  a flap  door  in  front,  hinged  at  the  top,  and  the  steam  turned  on,  through  the  screws, 
and  around  the  bale.  In  two  or  three  minutes  the  temperature  of  the  bale,  as  thus 
exposed,  can  be  raised  to  the  necessary  degree  of  temperature  throughout  and  sustained 
for  any  desired  length  of  time. 

The  experiments  were  as  follows  : — 

1.  Steam  at  seventy-five  pounds  : exposure  five  minutes.  Thermometer  at  supply 
heater  320°  F.,  followed  by  sixty-five  pouuds  pressure  at  same  exposure  to  550°  F. 
Result,  220°. 

Result. 

Thermometer  at  opposite  end  under  the  same  conditions 220°. 

“ under  wrapper  of  the  bale,  same  conditions 220°. 

“ three  inches  beneath  top  of  bale,  same  conditions..235°. 

2.  Steam  at  eighty  pounds  ; exposure  six  minutes.  Thermometer  at  supply  heater 
3G0°  F.,  and  420  F. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


575 


, Result. 

Thermometer  at  screw  end 280°. 

“ in  opposite  end 220°. 

“ four  inches  beneath  the  top 219°. 

“ on  top  of  bale 220°. 

3.  Steam  at  eighty  pounds  ; exposure  seven  minutes.  Thermometer  at  the  supply 
heater  490°  F. 

Result. 

Thermometer  in  top  of  bale 218°. 

“ in  screw  end  near  top 235°. 

“ in  the  side  under  the  band 410°. 

“ near  bottom  in  the  end  opposite  the  screw 305°. 


Several  vaccine  points,  number  ninety-eight,  in  a vial  wrapped  in  rags  and  under 
cover  on  top.  Several  vaccine  points  number  eighty-nine,  in  a vial  in  the  side  of  bale. 

Twenty-four  vaccine  points  were  submitted  to  the  test.  Twenty-three  primary  vac- 
cinations were  made  with  the  disinfected  virus,  all  of  which  were  failures. 

The  same  day  twenty-eight  vaccinations  were  made  with  non-disinfected  virus, 
twenty-seven  being  successful.  Both  the  disinfected  and  non-disinfected  virus  were 
taken  the  same  day,  from  the  same  calf.  (Report  of  Dr.  J.  B.  Taylor,  New  York, 
Board  of  Health . ) 

4.  Steam  at  eighty  pounds;  exposure,  eight  minutes.  Thermometer  at  supply  heater, 
490°  F. 


Result. 

Thermometer  in  under  side,  middle  of  bale 335° 

“ upper  “ “ “ 235° 

“ end  opposite  screw 220° 

“ “ •where  screw  enters 355° 


Several  vaccine  points  in  a vial  marked  “C,”  with  thermometer  at  top  of  bale, 
wrapped  in  rags.  Several  vaccine  points  (2d  No.  98),  with  thermometer  at  end  of  bale. 

5.  Steam  at  eighty  pounds;  exposure,  six  minutes.  Thermometer  at  supply  heater, 
330°  F. 

Result. 


Thermometer  in  bale  at  end 230° 

on  top,  five  inches  inside  of  bale 220° 

“ “ outside  of  bagging 220° 

(Five  screws.) 


6.  Steam  at  eighty-five  pounds;  exposure,  six  minutes.  Thermometer  at  supply 
heater,  405°  F. 

Result. 


Thermometer  in  bale  at  end 245° 

on  top,  five  inches  inside  of  bale 230° 

“ “ outside  of  bagging 225° 

(One  screw. ) 


7.  Steam  at  one  hundred  pounds;  exposure  eight  minutes.  Thermometer  at  supply 
heater,  500°  F. 

Result. 


Thermometer  on  top,  inside  of  bale 280° 

“ hung  at  end  of  bale 220° 

(Five  screws) 


8.  Steam  at  one  hundred  pounds;  exposure,  five  minutes.  Thermometer  at  supply 


heater,  500°  F. 

Result. 

Thermometer  on  top,  inside  of  bale 390° 

1 1 hung  at  end  of  bale 233° 

(Three  screws. ) 


576 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


9.  Steam  at  one  hundred  pounds;  exposure,  five  minutes.  Thermometer  at  supply 
heater,  500°  F. 

Result. 


Thermometer  on  top  inside  of  bale.... 

“ hung  up  at  end  of  bale. 
(One  screw. ) 


f 490° 
\ 480° 
f 320° 
\ 330° 


During  the  progress  of  these  experiments  the  time  was  frequently  cut  short  by  evi- 
dence of  scorching  or  combustion  of  the  rags,  by  the  odor.  The  liability  to  combustion 
depends,  to  a considerable  extent,  upon  the  character  of  the  rags,  it  being  by  no  means 
uncommon  to  find  in  the  bales  fragments  of  tarpaulin,  oakum  and  other  easily  combus- 
tible material.  But  to  avoid  this  liability,  as  well  as  to  secure  the  more  certain  and 
uniform  diffusion  of  the  temperature,  at  my  suggestion  a new  coupling  was  added,  for 
the  primary  injection  of  wet  steam,  before  passing  it  through  the  superheater,  for  five 
or  six  minutes,  and  immediately  thereafter,  for  an  equal  period,  superheated  steam. 
This  effectually  estopped  the  liability  to  combustion.  The  following  are  examples  of 
the  record: — 

10.  Steam  pressure,  eighty  pounds;  initial  temperature  of  supply  heater,  390°  F. ; 
time,  ten  minutes — five  each  of  wet  and  dry  steam. 

Result. 

Thermometer  on  bale,  near  back  end.. 220° 

“ “ <l  “ front  end 220° 

“ in  “ fifteen  inches  from  front  end,  near  1 9„_0 

the  centre.  / 


F. 


11.  Steam  pressure,  seventy-five  pounds;  initial  temperature  of  supply  heater, 
; time,  twelve  minutes — six  each  of  wet  and  dry  steam. 

Result. 


360° 


Thermometer  on  bale,  middle 220° 

“ in  “ fifteen  inches,  front  end 220° 

“ “ “ between  the  screws,  back  end 280° 


It  is  manifest  that  in  the  whole  series  of  experiments  above  detailed,  for  the  disin- 
fection of  rags  in  bale,  the  degree  of  temperature  attained  is  much  higher  than  necessary, 
except  with  reference  to  the  greatest  possible  dispatch  in  disinfecting  such  merchandise. 
It  should  be  remembered,  however,  that  the  apparatus  was  constructed,  and  the  engine 
adapted  to  its  use  (although  less  than  three  years  ago),  under  the  erroneous  impression 
that  it  was  necessary  to  apply  “a  temperature  of  not  less  than  330°  Fahrenheit,  forced, 
under  a pressure  of  four  atmospheres,”  by  direction  of  the  Hon.  Secretary  of  the 
Treasury  (McCulloch),  100°  higher  than  recommended  by  the  committee  of  the  con- 
ference of  the  representatives  of  the  State  Boards  of  Health,  held  in  Washington.  Decem- 
ber 10th-llth,  1884.  February  24th  following  (1885),  Dr.  Sternberg  communicated 
the  results  of  tests  he  made  with  the  same  apparatus  to  Dr.  Wm.  M.  Smith,  Health 
Officer  of  the  Port  of  New  York,  as  follows: — 

“ Moist  heat  proves  to  be  a most  certain  and  practical  method  of  destroying  germs, 
and  the  most  resistant  spores  are  quickly  destroyed  by  a temperature  of  230°  F., 
which  is  100°  below  the  temperature  exacted  by  the  Treasury  Department.  The  spores 
of  anthrax  are  destroyed  by  a temperature  of  221°  maintained  for  two  minutes,  and 
all  micrococci  and  bacilli  not  containing  spores  are  quickly  destroyed  by  a temperature 
much  below  the  boiling  point  of  water.”* 

But  under  Dr.  Sternberg’s  more  recent  conclusions  (ante)  and  the  now  general 


* “Report  on  Contagious  Diseases  Propagated  by  Rags,  to  the  Health  Department  of  New 
York,”  October  lGth,  1885. 


SECTION  XV — HJBLIC  AND  INTERNATIONAL  HYGIENE.  577 


acceptation  of  the  practical  results  that  steam,  at  a temperature  of  145°  F.,  is 
amply  sufficient,  it  is  clear  that  the  disinfection  of  haled  merchandise  may  be  effected 
with  <^r eat  facility  and  without  the  possibility  of  combustion  or  other  injury,  by  the  use 
of  the  same  machinery. 

It  would  not  be  well,  however,  to  restrict  the  power  of  the  steam  machinery  for 
quarantine  purposes  to  the  special  necessities  for  which  it  appears  to  have  been,  in  the 
first  place,  particularly  adapted— the  disinfection  of  baled  merchandise.  As  before 
demonstrated,  steam  can  be  applied  with  equal  certainty  to  infected  ships,  and  it  is 
sometimes  necessary  to  disinfect  both  ship  and  cargo  before  breaking  bulk — for  the  pro- 
tection of  the  stevedores — and  this  can  be  done  with  the  utmost  facility  and  certainty 
by  the  use  of  steam  without  injury  to  either  ship  or  merchandise;  but,  manifestly,  a 
large  head  of  steam,  some  additional  appurtenances — flexible  hose  of  sufficient  resist- 
ing power  to  heat — and  considerable  more  time  are  required  to  insure  the  plenary 
injection  of  steam  into  the  bilge,  throughout  the  limbers  and  all  other  recesses;  and  the 
more  time,  especially  if  an  iron  ship,  because  of  the  greater  capacity  for  heat. 

It  might  go  without  saying,  perhaps,  that  water  in  the  bilge  can  be  quickly  raised 
to  a boiling  temperature  by  the  injection  of  steam,  and  kept  so  ad  libitum. 

It  affords  me  special  pleasure  to  add  to  the  foregoing  the  following  communication 
from  Dr.  Joseph  Holt,  President  of  the  State  Board  of  Health  of  Louisiana,  describing 
the  disinfecting  apparatus  devised  by  him,  and  successfully  used  at  the  Mississippi 
Quarantine  Station  by  his  direction. 

Board  of  Health,  State  of  Louisiana,  New  Orleans,  August  28th,  1887. 

A.  N.  Bell,  m.d.,  Editor  The  Sanitarian,  New  York,  N.  Y. : — 

Dear  Doctor — In  reply  to  your  letter  requesting  of  me  a description  of  the  “ Steam  Super- 
heating Chamber  ” in  use  in  the  quarantine  station  of  this  port,  I have  the  honor  to  make  the 
following  statement : — 

The  quarantine  system  of  the  port  of  New  Orleans  is  essentially  one  of  disinfection;  detention, 
except  in  the  case  of  actually  infected  vessels,  never  exceeding  five  days. 

There  are  two  stations ; one  completely  isolated  and  intended  for  the  reception  of  infected  ves- 
sels only;  the  other,  for  general  inspection  and  sanitary  treatment  of  all  vessels  (except  those 
known  to  be  infected)  coming  from  quarantined  ports.  The  latter  (called  the  “Upper  Station”) 
is  the  one  at  which  the  greater  part  of  the  sanitary  work  is  accomplished. 

The  sanitary  treatment  consists  in  the  concurrent  application  of  three  (3)  processes;  first,  the 
wetting  of  all  available  surfaces  of  the  vessels  (excepting  cargo,  but  including  bilge,  ballast,  hold, 
saloons,  forecastle,  decks,  etc.,  with  a solution  of  the  bichloride  of  mercury  of  a strength  of 
1 :1000.  The  hatches  are  then  closed  and  the  entire  atmosphere  of  the  hold  is  displaced  by 
sulphurous  dioxide. 

While  this  is  going  on,  all  bedding,  ship’s  linen,  cushions,  mattresses,  flags,  mosquito  nets, 
curtains,  carpets,  rugs,  and  all  personal  baggage  and  wearing  apparel  of  whatever  description,  are 
removed  from  the  ship  to  a commodious  building  in  close  proximity,  in  which  these  articles  are 
treated  by  “ moist  heat,”  at  a temperature  of  not  less  than  230°  E. 

The  apparatus  for  this  work  consists  in  a steel  40-horse  power  steam  boiler  (Fig.  1 ),  connected 
with  a superheating  chamber  a few  feet  distant,  and  which  I will  now  describe. 

The  dimensions  of  this  chamber  taken  interiorly,  or  inside  measures,  are  GO  feet  long,  11  feet 
wide  and  7 feet  high.  The  framework  is  composed  of  3x3-inch  seasoned  pine  lumber,  joined 
just  as  in  the  construction  of  a wooden  house.  Upon  this,  outside,  excepting  the  front,  is 
nailed,  tongued  and  grooved  flooring  material,  J-inch  thick  by  6 inches  wide.  The  interior  of  the 
ends,  rear  side  and  top  are  ceiled  with  the  same  material,  and  a flooring  of  the  same  is  also  laid. 
Upon  these  interior  surfaces  is  tacked  “ heavy  Russian  hair-cloth  or  felting,”  and  upon  this,  at 
intervals  of  three  feet,  are  nailed  parallel  strips  of  wood,  l£x2  inches  thick,  and  in  turn  again 
upon  these  strips  is  fastened  another  layer  of  planking  as  already  described.  This  secures  an  air 
space  between  the  hair-cloth  and  the  inner  planking.  Upon  this  now  smooth  surface  of  wood  is 
finally  tacked,  and  held  in  place  by  broad-headed  nails,  or,  better,  by  nails  supplied  with  tin 
Vol.  IV. — 37. 


578 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


washers,  a double  layer  of  “asbestos  building  felt,”  well  lapped  and  securely  tacked,  thus  render, 
ing  the  interior  of  the  chamber  fire-proof,  a most  essential  provision.  By  the  foregoing  described 
consti uction  it  will  be  seen  that  the  walls  of  the  chamber,  which  are  eight  (8)  inches  in  thickness, 
consist  of  seven  (7)  non-heat-conducting  media:  First,  the  outer  layer  of  planking;  second,  three 
(3)  inches  of  air  space;  third,  an  inner  ceiling  of  planking;  fourth,  one  (1)  inch  thickness  of 
Russian  hair-cloth;  fifth,  one  and  one-half  (1£)  inches  of  air  space;  sixth,  a third  layer  of  f-ineh 
planking,  and  seventh,  a double  layer,  or  interior  lining  of  heavy  asbestos  felting. 

The  front  wall  is  divided  into  forty  (40)  panels,  eighteen  (18)  inches  wide  each,  which  repre- 
sent that  number  of  racks  contained  within  the  chamber.  Upon  the  bars  of  these  racks  the  cloth- 
ing, etc.,  is  hung  for  exposure  to  disinfection  by  moist  heat.  These  racks  are  constructed  with  a 
front  and  rear  panel,  united  by  horizontal  bars,  five  to  each  side.  Each  rack  is  suspended  over- 
head on  traveling  rollers  upon  an  iron  rod  which  extends  from  the  rear  wall  of  the  chamber  to  a 
support,  ten  feet  in  front  of  the  chamber;  the  rod,  therefore,  being  twenty  (20)  feet  in  length. 
By  this  arrangement  the  racks  may  be  drawn  out  and  pushed  in.  When  drawn  out  the  full 
length  of  ten  feet  the  rear  panels  of  the  racks  as  securely  close  the  chamber  as  the  front  panels  do 

Fig.  1. 


when  the  racks  are  pushed  in,  thus  admitting  the  heating  of  the  chamber  during  the  process  of 
hanging  the  articles  of  clothing,  etc.,  on  the  rack  bars  for  disinfection. 

The  interior  surface  of  each  front  panel  is  lined  with  a layer  of  Russian  hair-cloth,  over  which 
is  applied  a double  layer  of  asbestos  felting. 

At  intervals  of  seven  and  one-half  (7£)  feet  a bulkhead  of  one  (1)  inch  tongued  and  grooved 
flooring  material  is  placed,  subdividing  the  chamber  into  eight  (8)  compartments.  These  bulk- 
heads are  made  fire-proof  by  a covering  of  a double  thickness  of  asbestos  felting.  The  object  of 
this  arrangement  is  to  provide  against  the  spread  of  fire  in  the  event  of  its  occurrence.  In 
addition  to  this  provision,  there  is  a double  lead  of  one-inch  fire  hose  connected  with  a steam 
pump  near  the  boiler,  and  at  all  times  ready  within  fifteen  seconds’  notice  to  turn  on  two  streams 
of  water  upon  any  rack  on  which  fire  might  have  originated. 

The  superheating  of  this  chamber  is  so  provided  as  to  furnish  at  will  dry  or  moist  heat,  or 
both. 

Within  and  at  the  end  of  the  chamber  next  to  and  connected  with  the  boiler  are  two  (2)  mani- 
folds, one  above  the  other,  to  which  are  connected  a system  of  forty-five  (45)  3-inch  iron  steam 
pipes  (aggregate  5500  lineal  feet)  placed  horizontally  near  the  floor  of  the  chamber,  running  its 
full  length,  and  supplied  with  a bleeder  for  carrying  off  the  water  from  condensed  steam.  This 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  579 


furnishes  the  diy  heat.  Above  and  in  close  proximity  to  this  system  of  pipes  is  extended  a hori- 
zontal layer  of  galvanized  iron  4-inch  mesh,  to  catch  and  so  prevent  the  coming  in  contact  with  the 
superheating  pipes  of  any  article  accidentally  falling  from  the  racks. 

The  moist  heat  is  supplied  by  a 1-inch  steam  pipe  laid  centrally  in  the  midst  of  the  above 
described  dry  heat  pipes,  which  also  runs  the  entire  length  of  the  chamber,  constituting  a steam 
main  connected  with  the  boiler  and  controlled,  as  the  others,  by  a ball- valve  on  the  outside.  This 
pipe  is  perforated  by  forty  (40)  4-inch  holes,  so  placed  as  to  furnish  steam  to  each  rack. 

During  the  process  of  hanging  the  articles  of  clothing,  etc.,  on  the  racks,  the  dry  heat  is  turned 
on  and  the  temperature  of  the  chamber  raised  to  about  190°  F.,  made  known  by  a thermometer 
suspended  near  the  centre  of  the  chamber,  working  on  a slide,  which  is  drawn  forward  to  a glass 
panel  when  it  is  desired  to  make  a reading;  this  thermometer  has  a scale  of  285°  F. 

As  each  rack  is  filled,  it  is  pushed  back  into  place.  By  the  time  the  last  of  the  articles  have 
been  hung  on  the  racks,  the  entire  mass  of  the  material  within  the  chamber  has  attained  the 


Fig.  2. 


PERSPECTIVE,  LOOKING  TOWARD  BOILER-ROOM  OF  SUPERHEATING  CHAMBER,  ALL  THE  RACKS  PUSHED  IN. 
a.  Exterior  view  of  front  panels  of  racks,  b.  Traveling  rods  overhead,  c.  Fire-hose. 


above  mentioned  temperature,  and  the  free  steam  is  turned  on ; the  thermometer  speedily  rises  to 
a point  varying  between  230°  and  240°  F.,  at  which  it  is  maintained  for  a period  of  twenty  (20) 
minutes.  The  steam  pressure  in  the  boiler,  at  the  beginning  of  this  process,  registers  between 
100  and  110  lbs.  by  the  steam  gauge ; at  the  end  of  the  process  of  blowing  in  steam,  the  pressure 
will  have  fallen  to  about  60  lbs.  The  steam  is  now  entirely  cut  off  from  the  chamber  and  the  racks 
are  drawn  out  and  their  contents  removed.  During  the  process  of  steaming  every  article  is  per- 
ceived to  be  saturated  and  intensely  hot;  but  so  great  is  the  heat  in  the  texture  of  the  fabrics  as  to 
immediately  expel  all  moisture  upon  drawing  the  racks  and  exposure  to  the  open  air.  Shirts, 
collars,  etc.,  instantly  resume  the  crisp  dryness  they  possessed  before  exposure.  Silks,  laces,  the 
most  delicate  woolen  fabrics,  show  no  signs  whatever  of  the  treatment. 

Of  course,  articles  of  leather,  rubber  and  whalebone  would  be  injured  by  the  heat,  and 


580 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


are  therefore  disinfected  with  the  mercuric  solution  and  not  permitted  to  go  into  the  heating 
chamber. 

Time  required  to  charge  chamber  with  apparel  for  disinfection,  thirty  (30)  minutes;  time 
required  for  moist  heat,  twenty  (20)  minutes,  and  for  removal  of  articles  fifteen  (15)  minutes,  a 
total  of  sixty-five  (65)  minutes. 

A large  steamship,  particularly  a passenger  vessel,  may  require  two  or  three  charges  of  the 
chamber. 

Amount  of  coal  consumed  from  2 to  4 barrels  per  vessel. 

In  the  summer  of  18S5,  I devised  and  put  into  operation  a chamber,  exactly  of  the  above  speci- 
fications, but  wholly  inadequate  for  the  requirements  of  our  service.  This  was  replaced  by  one  of 
the  same  kind,  but  50  feet  in  length  and  supplied  with  a 20  horse-power  boiler,  which  latter  proved 
too  small  for  rapid  operation.  This  apparatus  was  burned  last  spring.  Our  present  chamber  and 
supply  boiler  are  of  the  dimensions  and  capacities  given.  The  cost  of  the  chamber,  supply  boiler 
and  fixtures  is  $2500.00. 


Fig.  3 


All  expressions  of  opinion  on  our  part  touching  the  relative  and  special  values  of  disinfectant 
agents,  in  “ Maritime  Sanitation,”  are  the  deductions  of  elaborate  and  expensive  experimental  work. 
While  in  practice  we  have  found  the  mercurial  solution  the  most  efficient  for  the  treatment  of 
ships’  surfaces,  and  the  sulphurous  acid  gas  or  sulphur  di-oxide  for  the  displacement  of  atmos- 
phere contained  within  the  ship’s  hold,  our  chief  difficulty  has  been  the  disinfectant  treatment  of 
baggage  and  other  textile  fabrics  expeditiously,  efficiently  and  without  injury  to  the  articles. 

The  application  of  chemical  agents,  in  any  form  suggested,  has  been  slow,  laborious  and  inju- 
rious, or  even  destructive  to  the  articles  disinfected. 

The  use  of  such  agents  has  cost  us  many  heavy  bills  of  indemnity. 

Schooled  by  necessity,  we  have  been  compelled  to  seek  in  moist  heat  a satisfactory  remedy.  In 
adopting  this  agent  we  were  greatly  enlightened  and  facilitated  by  the  published  official  reports 
and  papors  emanating  from  yourself  and  appearing  from  time  to  time  in  The  Sanitarian. 
Your  experience  in  regard  to  the  efficacy  of  moist  heat  as  applied  by  yourself  in  the  disinfec- 
tion of  yellow  fever  infected  vessels  of  the  U.  S.  Navy,  and  dating  as  far  back  as  1848,  has  iur- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  581 


nishccl  us  a substantial  groundwork  of  ascertained  fact,  upon  which  we  have  been  enabled  to 
build  our  present,  and  we  believe  perfected,  method  of  applying  steam  as  a disinfectant  agent 
in  one  of  the  most  important  departments  of  “ Maritime  Sanitation,”  regarding  heat  thus  used  as 
the  most  reliable,  economical  and  unobjectionable  germicide  available  in  practice. 

Yours  very  truly, 

Joseph  Holt,  m.d., 

President  Board  of  Health,  State  of  La. 


The  conclusions  fairly  deducible  from  the  foregoing  are  that — 

1.  Steam  at  a temperature  of  220°  F.  for  ten  minutes,  or  at  145°  for  two  hours,  is 
fatal  to  all  known  disease  germs. 

2.  The  various  devices  and  facilities  for  the  application  of  steam  for  the  purpose  of 

disinfectiou  are  abundant,  and  may  be  safely  left  to  the  direction  of  those  whose  duties 
require  their  exercise.  * 

DISCUSSION. 

Dr.  Joseph  Jones  said  that  he  regarded  the  paper  of  the  distinguished  sanita- 
rian as  one  of  great  value  and  importance  to  sanitarians,  and  he  regarded  Dr.  Bell  as 
the  first  American  to  apply  steam  for  the  disinfection  of  infected  ships.  The  results 
obtained  by  Dr.  Bell  have  stood  the  test  of  time  and  experiment.  I am  convinced 
that  steam  is  more  efficacious  and  far  less  dangerous  and  destructive  than  dry  heat. 

If  the  disinfecting  apparatus  is  defective  in  its  structure,  and  without  proper 
control  of  the  heat  and  proper  increase  of  the  air,  dry  heat  may  injure  the  articles 
subjected  to  it,  charring,  and  even  setting  fire  to  them. 

The  recent  accidents  at  the  Mississippi  Quarantine  Station  illustrate  the  import- 
ance of  regulating  the  degree  of  heat.  The  thermometer  suspended  in  the  air  does 
not  always  give  accurate  information  with  reference  to  the  temperature  of  the  wood 
and  metal  of  the  apparatus  or  drying  room,  and  they  may  gradually  attain  a tem- 
perature above  that  of  the  more  mobile  air. 

Dr.  M.  P.  Bedard,  of  Paris. — I desire,  with  my  honorable  confrere,  Bell,  to 
insist  before  the  Congress  upon  the  value  of  disinfection  by  steam.  From  many 
experiments  made  by  me  the  past  two  years,  it  results 

1.  Chemical  disinfectants  recommended  and  generally  employed  are  absolutely 
uncertain.  Certain  virulent  substances  do  not  lose  their  virulence  after  prolonged 
immersion  in  antiseptic  liquids. 

Carbolic  acid  is  no  more  efficacious  than  sulphate  of  zinc  and  chloride  of  zinc. 
These  last  two  disinfectants  may  attenuate  some  viruses  after  long  contact.  Nitro- 
sulphate  of  zinc  and  sulphur  have  shown  themselves  absolutely  inefficacious. 

2.  Disinfection  by  means  of  steam,  not  over-heated  and  not  above  110°  C.,  is 
inefficacious.  Steam  at  a temperature  of  90°-100°  C.  produces  attenuation  of  virus. 

3.  Absolute  disinfection — destruction  of  virus — can  only  be  obtained  by  super- 
heated steam  at  1 10°  C.  As  to  the  practical  side  of  the  question,  it  is  necessary  to 
build  simple  and  cheap  apparatus,  giving  superheated  steam  at  110°  C.  We  are 
now  studying  new,  simple  apparatus,  and  hope  soon  to  present  new  models  for  the 
disinfection  of  railroad  coaches,  rooms,  etc. 

Dr.  J.  A.  S.  Grant-Bey,  of  Egypt. — I read  a paper  at  the  Congress  in  Copen- 
hagen on  disinfecting  rags,  and  recommended  that  the  bales  should  be  broken  up. 

I have  now  changed  my  mind,  and  believe  it  is  safer  not  to  bring  them  into  the 
country  at  all. 

Dr.  A.  N.  Bell,  of  New  York. — My  paper  shows  that  steam  at  225°  F.  for  ten 
minutes,  or  145°  F.  for  two  hours,  will  destroy  any  germs. 


5S2 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ON  SOIL  DRAINAGE,  AND  OTHER  METHODS,  IN  THEIR  RELA- 
TIONS TO  THE  DEVELOPMENT  OF  MALARIAL  FEVER. 

SUR  LE  DESSECIIEMENT  DU  SOL,  ET  SUR  LES  AUTRES  METHODES  RELATIVES 
AU  DEVELOPPEMENT  DE  LA  PIEVRE  PALUDllENNE. 

UBER  BODENDRAINAGE  UND  SONSTIGE  METHODEN  IN  IHREN  VERHALTNISSEN  ZU  DER 
ENTWICKELUNG  DES  MALARIAFIEBERS. 

BY  THOMAS  HEBERT,  M.  D. , 

Of  New  Iberia,  La. 

By  this  communication  to  the  cause  of  public  and  international  hygiene,  the  author 
will  feel  amply  repaid  for  his  labors  if  he  succeed  in  successfully  soliciting  discus- 
sion, and  bringing  out  the  latest  thoughts  and  views  upon  the  important  subject  of  the 
prevention  of  malaria.  I disclaim  the  least  intention  of  being  exhaustive,  as  my  pur- 
pose is  only  that  which  has  just  been  mentioned.  No  elaborate  treatment  will  even 
be  attempted  by  me  in  the  inadequate  and  cursory  view  of  the  subject  here  presented. 

Two  practical  questions  of  primary  and  pressing  importance  arise  in  the  considera- 
tion of  malaria  and  its  manifestations.  One  of  these  is  the  efficacious  treatment  of  the 
disease  in  persons  of  indi  viduals,  and  its  prevention  either  in  regard  to  its  return  after  cure, 
or  its  outbreak  in  persons  subject  to  its  occurrence.  The  other  is  the  correction  of  such 
influences  as  favor  its  evolvement,  which  arise  in  climate  and  conditions  of  soil,  as  far 
as  may  be  practicable  to  us  by  our  short  and  inadequate  measures  of  sanitary  ameliora- 
tion. The  first  reference  belongs  to  the  domain  of  therapeutics  and  personal  hygiene; 
the  second  is  fitly  embraced  under  the  head  of  general  hygiene,  or  sanitation  of  com- 
munities. Several  well-established  facts  in  regard  to  the  behavior  of  the  malarial 
poison,  which  relate  more  especially  to  its  physical  properties  as  a form  of  matter,  have 
long  been  matters  of  observation  to  the  profession,  of  which  we  may  take  a passing 
view  before  arriving  at  the  heart  of  the  questions  herein  considered. 

We  know,  for  instance,  from  facts  too  well  known  to  be  doubted,  that  malaria,  in  its 
specific  sense,  is  an  outcome  or  emanation  from  the  soil,  receiving  its  production  and 
development  from  conditions  existing  in  the  soil,  and  probably  from  matter  in  an 
organized  state,  as  a necessary  factor  in  its  production. 

Its  telluric  origin  would  be  impossible  without  the  concomitant  cooperation  of  heat, 
air  and  moisture. 

We  are  aware  of  the  fact  that  the  morbific  material,  of  whatever  nature  or  form  it 
is,  finds  its  avenue  of  dissemination  generally  in  the  atmosphere,  or  in  water  or  other 
liquids  which  have  become  impregnated,  primarily  or  secondarily,  with  the  poison,  and 
that  through  the  atmosphere  the  disease  breeding  agent  may  spread  over  an  extent  of 
country  miles  away  from  its  locality  of  origin. 

Its  material  nature  aud  more  or  less  ponderous  character  is  demonstrated  by  the 
fact  that  a line  of  forest  or  densely  aggregated  trees,  or  sufficient  rise  of  ground,  may 
prevent  its  propagation  in  the  direction  barred  thereby. 

This  fact  suggests  another  of  considerable  importance  relative  to  the  occurrence  of 
an  outbreak  of  the  disease  in  certain  defiued  localities  favorably  situated  for  the  occur- 
rence of  the  phenomenon,  which  exists  in  the  obvious  relation  between  the  greater  pre- 
valence of  the  disease  and  the  direction  of  winds  which  blow  over  the  localities  where 
malaria  is  being  generated.  I have  observed,  and  others  no  doubt  have  had  a similar 
opportunity,  that,  for  example,  when  the  winds  are  prevalent  from  the  southern  and 
eastern  quarters,  as  is  the  case  most  of  the  time  in  spring  and  summer  in  the  northern 
hemisphere,  with  some  exceptions,  maybe,  the  spread  of  malaria  is  generally  to  a 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  583 


greater  extent  upon  the  north  and  west  side  of  streams  and  marshes ; and  although  in 
most  instances  the  relative  preponderance  of  cases  in  certain  localities  in  communities 
affected  may  not,  under  circumstances  alluded  to.  be  well  marked  or  sharply  defined, 
I have,  nevertheless,  made  it  a matter  of  well-authenticated  and  corroborated  observa- 
tion that  such  a relation  as  here  expressed  does  exist  between  the  prevalence  of  winds 
and  the  propagation  of  malarial  fever. 

These  facts  and  others  not  mentioned  here,  going  to  prove  or  demonstrate  that 
malaria  is  something  originating  in  the  soil  or  in  decaying  vegetable  matter,  the  pro- 
duct of  the  soil,  the  practical  question  to  which  they  lead,  for  us  to  consider  specially, 
is  in  regard  to  the  feasibility  of  methods  by  which  the  origin  and  prevalence  of  malarial 
disease  may  he  more  or  less  effectually  prevented.  A matter  of  observation  may  be 
scientifically  important  or  interesting,  and  yet,  for  the  utilitarian  or  worker  in  the  lines 
and  avenues  of  every-day  practical  life,  may  not  he  worth  the  trouble  or  labor  of  its 
acquisition.  But  there  is  a lesson  in  this  subject  of  the  origin  of  malaria  which  bears 
for  us  an  important  significance,  and  which  may  enable  us  to  formulate  and  exercise 
efficient  methods  by  which  the  manifestations  of  this  pathological  agent  may  some- 
times he  more  or  less  effectually  stamped  out  of  existence  or  very  materially  modified 
in  communities  subject  to  its  pernicious  influence. 

When  the  drainage  of  a marsh  or  low-lying  locality  reeking  from  moisture  is 
possible,  its  noxious  properties  may  be  obviated.  In  this  plain  method  we  have  indi- 
cated the  readiest  and  generally  the  most  efficacious  and  economical  means  by  which 
malarial  disease  may  be  obliterated  from  a locality  where  it  is  prevalent.  The  question 
of  drainage  is  one  which  rises  to  the  attention  of  the  sanitarian  as  belonging  to  the 
alphabet  or  first  principles  of  Hygiene.  But  to  be  efficacious  or  successful  in  the 
attainment  of  its  object  drainage  must  be  thorough  and  complete.  Partial  drainage  of 
a marsh,  pond,  low-lying  place,  or  basin  for  moisture,  which  abstracts  the  bulk  of 
the  water  and  allows  more  or  less  to  remain  indefinitely,  stagnant  in  pools,  or  as  sat- 
urating the  spongy  soil,  is  worse  than  useless,  since  such  water  remains,  to  disappear 
slowly  by  evaporation,  giving  time  and  the  best  conditions,  I believe,  for  the  malarial 
poison  to  be  generated.  If  the  soil,  in  other  words,  by  such  drainage  cannot  be  left  in 
a condition  to  be  desiccated  by  the  sun  heat  in  the  ordinary  time  required,  for  instance, 
to  dry  up  high  ground  after  heavy  rains,  or  if  after  a certain  reasonable  length  of 
time,  it  will  be  exactly  in  the  condition  most  favorable  for  the  development  of  the 
malarial  poison.  Of  course,  if  such  drainage  can  ultimately  leave  the  soil  in  such 
condition  as  to  achieve  the  purpose  of  thorough  drainage,  then  it  may  be  classed  as  effi- 
cacious and  beneficial,  although  its  effects  may  not  be  immediate. 

After  heavy  raius  which  completely  cover  with  water  low  places  and  help  to  purify 
the  atmosphere  by  precipitating  floating  particles  therefrom,  and  which  also  cause  a 
repletion  of  small  streams,  the  soil  of  marshy  places  or  the  damp  edges  of  streams  may 
cease  for  the  time  being  from  generating  miasms.  When  such  an  occurrence  takes 
place  to  an  extent  sufficient  in  degree  to  cover  totally  a marshy  soil,  or  fill  to  repletion 
the  streams  of  a locality,  I have  noticed  a cessation  in  the  occurrence  of  new  cases  of 
malarial  fever  sufficiently  well  marked  to  demonstrate  decidedly  a close  relationship 
between  the  amount  of  rainfall  and  the  degree  of  prevalence  immediately  afterward 
(not  for  a season)  of  cases  of  malarial  fever. 

The  theory  here  intimated  or  understood  is  that  where  and  when  the  ordinary  forms 
of  vegetation,  applying  the  statement  universally,  which  have  their  roots  necessarily 
in  the  soil  for  the  possibility  of  growth,  cannot  find  the  necessary  conditions  for  their 
germination  and  growth,  malaria,  which  is  a product  of  the  soil,  which  seems  to  require 
essentially  heat,  air,  and  moisture  for  its  production,  will  also  fail  to  find  the  circum- 
stances favorable  to  its  growth  and  propagation.  If  (and  this  has  been  a matter  of  com- 
mon observation  to  all  physicians  familiarized  with  the  manifestations  of  the  disease 


584 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


dependent  upon  its  evolution  and  dissemination),  under  these  circumstances,  malaria 
will  not  be  generated,  no  new  cases,  or,  as  stated  before,  but  few  will  occur  during  the 
time  that  the  atmosphere  remains  free  from  the  poison.  But  as  soon  as  these  waters 
drain  off  or  are  evaporated  and  the  heat  of  the  sun  begins  to  set  up  fermentative  and 
germinative  action  in  the  damp,  exposed  edges  and  stretches  of  the  surface  of  the  soil 
inadequately  drained,  malaria  is  generated  anew,  and  we  have  in  localities  subject  to 
its  influence  a fresh  outbreak  of  cases  of  the  disease,  attendant  upon  its  presence  in  the 
atmosphere. 

From  this  series  of  phenomena  I have  been  able  to  determine  approximately  the 
time  that  is  consumed  in  the  production  or  generation  of  the  malarial  poison,  its  dis- 
semination in  the  atmosphere  and  the  outbreak  of  the  disease  in  persons  most  directly 
subject  to  its  influence.  This  period  varies  from  a few  hours  or  five  or  six  days  to 
fifteen.  The  first  factor  in  the  production  of  this  period,  that  of  the  production  of  the 
poison  and  the  contamination  of  the  atmosphere,  is,  all  things  being  equal,  more  or  less 
fixed  and  constant,  I presume,  in  comparison  to  the  second,  the  incubation  of  the  germ 
in  the  blood,  which  is  variable. 

Knowing  this,  the  possibility  of  effectively  preventing  the  prevalence  of  malaria 
by  a system  of  quick  and  thorough  drainage  and  drying  of  the  soil  producing  it  is 
apparent.  In  the  spring  of  the  year,  when  the  farmers  prepare  the  soil  for  cultivation 
and  rains  are  generally  frequent,  the  upturned  soil  remains  damp  and  loose  for  a con- 
siderable length  of  time,  and  our  vernal  fevers  are  the  result.  They  are  generally  uni- 
versal in  the  region  being  thus  prepared  for  tillage,  thus  showing  their  dependence  to 
be,  one  of  effect  to  cause,  upon  the  changes  produced  by  the  plow  in  the  condition  of  the 
soil.  But  after  some  time  these  fevers  cease,  to  give  place  later  to  severer  forms  of  the 
disease. 

Theoretically,  the  question  of  perfect  drainage  of  the  soil,  so  that  its  thorough  desic- 
cation is  the  work  of  the  shortest  possible  time,  is  undoubtedly  the  best  solution  to  the 
problem  of  the  readiest  and  most  economical  method  of  preventing,  as  much  and  as  far 
as  lies  in  our  power,  the  formation  and  the  outspreading  of  the  malarial  poison.  No 
doubt  this  question  of  drainage  is  the  explanation  of  the  fact  that,  as  this  country  has 
gradually  been  reclaimed  from  the  wilderness,  improved,  tilled  and  drained,  malarial 
fever  has  proportionately  become  less  virulent  and  less  universally  prevalent.  But  there 
remains  a vast  amount  of  territory  to  which  the  methods  of  sanitary  care  and  treatment 
might  be  applied,  where  practicable,  with  great  and  lasting  benefit  to  those  human 
beings  who  are  suffering  from  the  effects  of  malarial  toxcemia. 

There  are  low  basins,  however,  especially  in  the  strictly  alluvial  districts  of  this 
country,  to  which  no  economical  system  of  thorough  drainage  could  effectively  be 
applied.  There  are  ponds  and  marshes  which  cannot  be  effectually  drained,  as  there 
are  such  places  to  which  no  system  whatever,  of  sanitary  treatment,  can  practically  be 
applied  as  a whole.  The  immense  low  swamps  of  Louisiana  and  other  States  are  an 
example  of  this  inability  of  the  sanitarian  to  meet  the  requirements  of  the  case.  For 
such  regions  the  only  practicable  plan  is,  that  they  should  gradually  be  reclaimed, 
where  possible,  settled  and  tilled.  Again,  however,  localities  in  question  exist  which 
cannot  be  effectually  drained,  but  to  which  other  measures  may  sometimes  be  applied, 
achieving  the  same  end  as  drainage.  I refer  in  this  connection  to  two  procedures  which 
naturally  occur  to  the  mind  as  succedanea,  or  even,  where  more  economical,  or  under 
circumstances  preferably  favoring  their  application,  more  efficacious  and  more  to  be 
desired  than  drainage.  One  of  these  methods,  to  which  only  a short  reference  need  be 
made,  is  the  filling  up  on  a level  with  surrounding  higher  ground  of  low  places  and 
shallow  ponds,  etc.,  wlieu  practicable,  so  as  to  leave  no  depressions  or  hollows  to  retain 
water  or  moisture.  This  method  must  of  necessity  be  very  limited  in  its  application, 
as  the  work  necessary  to  accomplish  the  obliteration  of  localities  of  any  considerable 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  585 


extent  bearing  the  characters  in  question  would  cost  more  in  the  payment  of  labor, 
etc.,  than  most  communities  would  he  able  to  pay.  There  are,  however,  innumerable 
localities,  foci  of  generation,  which  embrace  but  a small  area  of  surface,  shallow  ponds, 
as  in  southwestern  Louisiana,  over  the  prairies,  and,  almost  invariably  there  adjoining 
residences,  which  are  hotbeds  of  malaria  for  those  persons  who  inhabit  their  immedi- 
ate neighborhood,  and  also  for  some  considerable  distance  away.  In  the  hot  season  of 
July,  August  and  September  such  depressions  are  tor  the  most  of  the  time  in  a semi- 
dry condition,  affording  the  opportunity  for  malaria  to  find  its  most  favorable  conditions 
of  development.  Obviously,  the  filling  up  or  obliteration  of  such  places  is  the  readiest, 
most  efficacious  and  economical  means  of  dealing  with  them,  from  a sanitary  point  of 
view,  judging  by  the  topographical  conformation  of  the  regions  in  question. 

Whether  malaria  finds  its  nidus  in  the  soil  directly,  or  in  decaying  vegetable  matter, 
the  product  of  the  soil,  it  is  certain  that  its  prevention  in  localities  where  it  is  rife 
would  greatly  conduce  to  the  mental  and  material  welfare  of  those  who  habitually  are 
laboring  under  its  repeated  visitations.  In  countries  subject  to  overflow,  or  in  those 
sections  where  the  flooding  of  rice  fields  offers  opportunities  for  study,  malaria  does  not 
affect,  to  any  great  or  appreciable  extent,  the  inhabitants  of  these  localities  as  long  as 
the  water  is  not  receding  from  the  surface  of  the  ground.  But  it  makes  its  appearance 
upon  the  heels  of  the  waters  in  their  recession,  and  is  manifested,  ‘ ‘ cseteris  paribus,  ’ ’ 
most  universally  and  virulently  when  the  greatest  amount  of  damp  soil  covered  with 
decaying  vegetable  matter  is  exposed  to  the  sun,  and  is  strongest  in  such  manifestations 
when  the  recession  of  waters  takes  place  in  the  hottest  season  of  the  year. 

Localities  to  which  the  foregoing  methods  can  be  applied  will  be  found  to  exist  in 
all  malarial  districts,  and  in  any  case  the  choice  of  a method  by  which  the  sanitary  , 
condition  of  a locality  may  be  improved  will  mostly  be  a question  of  financial  economy 
and  material  aptitude.  Under  certain  natural  arrangements  of  the  topographical  fea- 
tures of  a locality,  we  may  sometimes  find  that  the  malarial  focus  of  generation  is 
limited  to  a well-defined  and  comparatively  small  area  of  surface,  and  that  the  neigh- 
borhood of  an  abundant  supply  of  water  will  facilitate  the  application  of  the  principle 
of  flooding,  as  illustrated  by  the  natural  phenomena  alluded  to  above,  in  freshets  and 
rice  flooding.  Where  practicable,  this  means  of  arresting  the  generation  and  diffusion 
of  malaria  is  as  efficacious,  may  be,  as  either  of  the  two  others  already  alluded  to  in 
the  preceding  remarks.  But,  of  necessity,  this  means,  as  that  which  effects  the  oblit- 
eration of  small  malarial-bearing  ponds,  marshes  and  other  damp  and  noxious  places, 
by  filling  them  up,  is  one  which  falls  short  of  an  aptitude  for  general  application.  So 
few,  indeed,  may  be  the  opportunities  of  having  recourse  to  this  measure  of  preven- 
tion, that  the  sanitarian  may  be  called  upon  but  seldom  to  advise  and  enforce  its  appli- 
cation. 

No  stagnant  water,  in  case  of  such  flooding,  must  be  allowed  to  lay  upon  the  soil, 
and  the  presence  of  the  water  must  be  maintained  until  the  arrival  of  the  cold 
season  shall  put  a stop  to  the  processes  by  which  the  malarial  bacillus  is  generated. 
With  these  general  methods  the  sanitarian,  whose  field  of  inquiry  and  operation  is 
embraced  within  the  bounds  of  malarial  districts  of  country,  will  be  concerned,  for  the 
welfare  of  humanity  and  the  advancement  of  race  will  demand  of  him  an  increase  of 
knowledge  and  a further  perfection  of  means  and  measures  as  the  enlightenment  and  pro- 
gress of  communities  advance,  for  there  can  be  no  doubt  that  malaria  is  a factor  in  the 
retardation  of  mental,  material  and  physical  progress,  and  that  its  production  and 
effects  are  to  be  deplored  and  arrested,  as  far  as  our  limited  means  will  permit  us. 

In  conclusion,  a general  view  of  this  subject,  embraced  in  three  propositions,  will 
serve  to  give  a clearer  understanding  of  the  subject,  one  which  is  of  vital  importance 
to  a very  large  proportion  of  the  inhabitants  of  this  country  and  others,  and  which 
merits  the  serious  attention  of  the  guardians  of  the  public  health. 


586 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


The  first  of  these  is  as  follows:  Drainage,  free,  complete  and  thorough,  by  which  a des- 
iccation of  the  soil  and  decaying  vegetable  matter  may  be  achieved  in  the  shortest  pos- 
sible time,  and  the  effects  of  which  are  to  remain  as  permanent  as  the  circumstances  of 
the  case  will  allow. 

2.  In  localities  which  permit  its  economical  and  thorough  application,  the  filling  up 
or  obliteration  of  low-lying  places  may  sometimes  be  the  readiest  and  most  efficacious 
means  at  the  choice  of  the  sanitarian. 

3.  Where  neither  of  these  measures  may  suitably  be  applied,  flooding,  where  the 
natural  conformation  of  the  surface  of  the  earth  and  a free  supply  of  water  may  be 
drawn  upon  when  favorably  situated  for  the  purpose,  is  a rare  means  which  might 
sometimes  be  found  applicable  to  the  arrest  of  the  growth  and  dissemination  of  the 
miasmatic  emanations  from  the  soil. 

Unfortunately,  a large  area  of  disease-breeding  soil  will  always  remain  inaccessible 
to  the  sanitarian,  a part  of  which  can  ultimately  he  improved  by  the  changes  produced 
in  the  condition  of  a country  by  its  settlement,  habitation,  tillage  and  drainage  for  the 
purposes  of  cultivation  and  the  needs  of  civilized  life. 

I have  not,  in  the  consideration  of  the  sanitary  treatment  of  malarial  localities, 
taken  cognizance  of  all  the  points  of  interest  and  utility  suggested  by  the  subject. 
Cleanliness  of  habitations  and  their  surroundings,  and  prophylaxis  in  person,  although 
so  very  important,  belong  to  other  divisions  of  the  general  subject.  The  cleanliness  of 
malaria-bearing  localities,  embracing  the  removal  of  vegetable  matter  which,  in  a 
decaying  condition,  offers  food,  if  I may  so  say  it,  for  the  poison,  is  of  sufficient  import- 
ance in  itself  to  merit  serious  attention,  and  should,  of  course,  be  attained  as  much  as 
possible.  The  details  of  any  particular  system  of  sanitation  are  not  to  be  considered 
here,  and  would,  if  introduced,  stretch  this  paper  beyond  the  limits  of  your  patience, 
for  which,  in  conclusion,  allow  me  to  express  my  thanks. 


DISCUSSION. 

Dr.  A.  Nash,  of  Illinois. — The  gentleman  has  advanced  the  idea  that  drainage 
will  check  the  malaria.  In  our  section  I have  found  that  draining  of  the  standing 
water  during  the  summer , or  malarial  season,  is  invariably  followed  by  an  outburst 
of  remittent  and  intermittent  fevers.  The  ultimate  drainage  of  the  soil  is.necessary 
and  proper,  but  it  should  never  be  uncovered  during  the  hot  months ; there  is  left 
then  a half-dried  slime,  from  which  malarial  emanations  poison  the  neighborhood. 

Dr.  James  A.  Martin,  of  Kansas. — Iu  my  opinion  the  malaria  in  our  countiy 
proceeds  chiefly  from  standing  pools  of  stagnant  water. 

Dr.  W.  L.  Sciienck,  of  Osage  City,  Kansas. — I know  that  none  of  you  will  agree 
with  me ; but  who  has  seen  this  concealed  organism  which  is  so  much  talked  about? 
It  is  beyond  the  microscope.  I believe  the  heat  and  great  changes  from  heat  to 
cold,  warm  days  and  cool  nights,  cause  congestion — congestion  of  internal  organs ; 
this  brings  on  fever  and  the  other  symptoms  which  we  call  malaria.  I know  you  do 
not  agree  with  me,  but  the  great  authority,  Stokes,  I may  refer  to  for  some  of  my 
opinions. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


587 


FIFTH  DAY. 


THE  NECESSITY  FOR  TEACHING  HYGIENE  IN  SCHOOLS. 

L’ENSEIGNEMENT  NECESSAIRE  DE  L’HYGIENE  DANS  LES  ECOLES. 

UBER  DIE  NOTHWENDIGKEIT  DES  HYGIENISCHEN  UNTERRICHTES  IN  DEN  SCHULEN. 

BY  W.  C.  COOK,  M.D., 

Of  Nashyille,  Tennessee. 

Notwithstanding  the  efforts  of  sanitarians  in  recent  years  to  enlighten  the  world 
upon  the  importance  of  public  hygiene,  as  a most  economic  and  essential  element  in 
human  progress  and  happiness,  the  sad  fact  still  remains  that  the  greatest  obstacle  in 
the  way  of  advancement  is  ignorance  and  consequent  indifference  of  the  masses  upon 
this  vital  question.  This  is  truly  shown  by  the  opposition  with  which  vaccination  is 
met  by  a large  per  cent,  of  every  community,  although  for  nearly  a century  it  has 
been  demonstrated  to  he  an  unfailing  preventive  of  a most  loathsome  and  dangerous 
disease.  This  was  clearly  evident  among  the  negroes  at  Nashville,  during  a fearful 
epidemic  of  smallpox,  in  1882-4. 

They  have  but  little  fear  of  smallpox,  believing  it  to  be  a God-given  disease.  The 
more  superstitious  of  them  regard  it  as  an  evidence  of  religious  courage,  mortification  of 
the  flesh  and  acceptance  with  God,  to  bravely  face  it,  as  a direct  visitation  of  Divine 
Providence.  Hence,  they  firmly  believe  and  say,  when  the  vaccinator  proposes  to 
protect  them  by  the  operation,  “Go  ’way  from  here  wid  your  scratch  pins.  You 
can’t  keep  off  smallpox.  God  gibs  us  dat,  and  you  can  do  no  good  wid  your  baccinate. 
If  I’s  gwine  to  hab  de  smallpox,  I’s  gwine  to  hab  it.”  Some  affect  to  believe  that  the 
doctor  vaccinates  with  smallpox  matter,  or  some  poisonous  substance,  which  gives  them 
disease  and  kills.  So  a large  per  cent,  of  the  lower  class  of  the  negroes,  and  many  of 
the  same  class  of  whites,  have  never  submitted  to  the  operation,  and  never  will.  It  is 
frequently  the  case,  when  smallpox  appears  in  a family,  and  all  the  other  members  are 
unvaccinated,  that  they  refuse  to  heed  the  admonition  of  the  doctor,  and  be  protected. 
Hence,  the  contagion  spreads  from  one  to  another. 

Another  reason  why  the  disease  has  been  so  difficult  to  manage  is  the  refusal  of  the 
afflicted  families  to  maintain  isolation  of  cases.  So,  from  ignorance  and  superstition 
mainly,  a large  portion  of  the  sick  people  refused  to  enter  the  hospital,  or  to  be  vaccin- 
ated or  isolated,  and  its  ravages  were  continued  for  more  than  two  years. 

As  knowledge  has  extended,  other  diseases  have  alike  been  proved  to  be  caused  by 
or  dependent  upon  such  conditions  as  are  certainly  avoidable.  Typhoid  fever,  dysen- 
tery, diarrhoea,  and  other  forms  of  bowel  troubles,  have  many  times  been  demonstrated 
to  be  caused  by  contaminated  drinking  water.  Klein  has  shown  that  scarlet  fever  is  a 
disease  derived  from  the  cow  through  the  medium  of  the  milk.  Measles,  diphtheria,  and 
possibly  all  infectious  diseases,  in  most  instances  are  controllable  or  preventable.  Much 
of  the  ill  health  of  all  communities  is  known  to  result  from  the  unsanitary  conditions 
which  are  found  to  exist,  and  yet  how  impossible,  often,  it  is,  under  the  prevailing 


588 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


insubordination  and  general  lack  of  information  upon  the  necessities  of  hygiene  among 
the  masses,  for  health  officers  to  induce,  or  enforce,  a compliance  with  rules  and  regu- 
lations for  their  removal. 

This  lack  of  information  and  consequent  indifference  as  to  sanitary  methods  is  not 
confined  to  the  people  only,  but  is  often  as  striking  among  those  who  are  called  upon  to 
represent  them  in  the  legislatures  of  the  country.  Like  them,  they  have  not  yet  been 
brought  to  the  proper  study  of  the  problem. 

An  intimate  acquaintance  with  a number  of  Tennessee  legislatures  enables  me  to 
state  that  most  members  will  only  endorse  and  promote  such  measures,  as  they  say, 
“as  my  people  want,”  with  a natural  disposition  not  to  encourage  anything  new,  unless 
there  is  a manifest  demand  for  it. 

My  observation,  with  much  evidence  besides,  goes  to  show  that  in  large  communi- 
ties the  food  supply,  especially  live  stock  and  dressed  meats  and  sausages,  offered  for 
sale,  should  receive  not  only  closer  inspection  by  health  officers  and  boards  of  health, 
but  with  a view  of  securing  a purer  supply  should  be  the  subject  of  special  legislation. 
I am  informed  by  butchers,  and  the  inspection  of  our  sanitary  officers,  that  often  sick, 
poor,  bruised  and  tired  beef  cattle  are  received  or  offered  for  sale  as  food  in  our  market. 
Adulteration  of  many  of  the  chief  articles  of  diet,  such  as  butter,  syrups,  teas,  canned 
goods,  spices,  etc.,  are  known  to  exist,  especially  in  large  cities,  as  New  York,  Phila- 
delphia, Boston,  and  elsewhere.  In  the  recent  Legislature  of  our  State  a well-prepared 
bill  was  introduced  with  the  view  of  securing  the  proper  inspection  of  live  stock, 
dressed  meat  and  sausages  intended  for  food  in  cities  of  over  70,000  population  at  least, 
but  the  ready  defeat  of  the  measure  showed  conclusively  how  little  sympathy  or  inter- 
est the  average  legislator  has  in  sanitary  affairs.  The  bill  was  voted  down  in  the  Senate  by 
twenty  to  four,  upon  the  presumption,  as  an  honorable  Senator  remarked  to  the  writer, 
“ that  it  was  a slap  in  the  face  of  the  farmer,  and  was  thought  to  operate  against  his  inter- 
est,” as  if  the  farmer  in  offering  his  meat  for  sale  in  the  market  has  greater  rights  than 
those  who  buy  and  eat  it.  Many  States  in  this  and  other  countries  protect  public 
health  and  trade  by  rigid  laws  upon  the  subject.  The  active  opposition  displayed  by 
our  law  makers  as  to  the  bill  clearly  shows  how  far  behind  we  are  in  the  progress  and 
enlightenment  of  the  age. 

Health  officers,  boards  of  health,  physicians,  and  sanitarians  should  feel  an  especial 
obligation  resting  upon  them  to  renewed  effort  in  educating  the  masses  upon  this  and 
kindred  subjects,  by  a more  thorough  dissemination  of  sanitary  knowledge.  It  is 
said  that  when  the  people  of  Great  Britain  discovered  that  more  than  one  hundred 
articles  were  adulterated,  the  British  Parliament,  as  long  ago  as  1815,  passed  the  best 
law  extant,  and  since  known  as  the  “Food and  Drugs  Act.”  The  present  Legislature 
passed  a law  looking  to  the  manufacture  of  a purer  article  of  candy,  which,  while  it  is 
to  be  certainly  approved,  it  is  nevertheless  difficult  to  see  that  a similar  bill  to  secure 
pure  and  wholesome  meats  is  less  important.  We  are  liable  to  be  imposed  upon  by 
having  placed  upon  our  market  cattle  afflicted  with  Texas  fever,  pleuro-pneumonia, 
tuberculosis,  and  other  contagious  diseases  among  cattle  in  the  absence  of  authorized 
inspection,  which  are  calculated  to  prejudice  the  health  of  the  people. 

The  popular  mind  should  be  brought  to  realize  the  fact  that  in  divers  ways  they  are 
being  imposed  upon,  either  by  ignorance  or  the  greediness  and  unscrupulousness  of 
vendors  of  articles  supposed  to  be  necessary  for  their  health  and  comfort.  Medicines 
even,  the  first  and  last  means  to  which  we  resort  for  the  relief  of  suffering  humanity 
and  the  prolongation  of  life,  are  alike  subject  to  adulteration,  or  else  placed  upon  the 
market,  with  flaming  advertisements,  in  the  shape  of  some  worthless  elixir,  a panacea 
for  some  or  all  the  ills  to  which  human  flesh  is  heir.  Krauss,  chemist  of  Memphis 
recently  analyzed  a specimen  of  a proprietary  medicine  under  the  extravagantly  adver- 
tised name,  “Tasteless  syrup  of  quinine,”  highly  recommended,  he  states,  by  two  very 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  589 


reputable  physicians  of  my  own  town  (Nashville),  and  “found  it  to  be  not  quinine,  but 
pure  commercial  cinchonine,  the  basest  of  all  cinchona  alkaloids.”  This  is  only  one 
instance  of  thousands  similar  that  have  come  to  light.  In  these  degenerate  days  the 
proper  thing  to  do  would  be  to  have  all  articles  intended  for  food  or  medicine  for  man 
subjected  to  authorized  and  competent  inspectors.  To  do  so,  the  people  must  be 
taught  the  necessity.  Once  thoroughly  informed,  all  needed  legislation  and  compli- 
ance therewith  would  follow. 

In  order  to  secure  with  greater  efficiency  necessary  laws  and  to  promote  in  the  high- 
est degree  public  hygiene  in  all  of  its  departments,  every  effort  should  be  made  to 
instill  its  principles  into  the  popular  mind. 

For  this  the  first  class  to  whom  we  should  appeal  is  the  medical  profession  itself. 
They  are  by  nature,  education  and  practice  tbe  guardians  of  the  health  of  the  commu- 
nities in  which  they  live,  and  from  every  consideration  better  acquainted  with  the  sani- 
tary demands  which  surround  them  than  any  other  class  of  people  in  their  midst. 
Moreover,  they  are  usually  faithful  workers  for  the  public,  without  money  and  without 
price.  They  only  need  to  recognize  a little  more  sharply  the  fact,  and  act  accordingly, 
that  preventive  medicine  is  the  medicine  of  to-day,  and,  as  Dr.  Brunton  says,  perhaps 
in  the  near  future  doctors  will  be  paid  rather  to  keep  people  well  than  to  treat  them 
when  sick,  observing  that  1 ‘ this  branch  of  medicine  has  been  greatly  aided  by  the 
recent  increase  of  our  knowledge  of  the  life  history  of  microbes,  and  their  action  in 
causing  disease.  Our  power  to  prevent  disease  will  become  greater  when  we  know 
accurately  the  action  of  various  drugs  in  destroying  these  microbes,  or  preventing  their 
growth.” 

Medical  practitioners  are  invaluable  coadjutors  to  health  officers,  in  that  they  con- 
stitute a vast  army  of  thinkers  and  readers,  who  are  therefore  enlightened  and  efficient 
instructors,  or  may  become  so,  of  the  modern  gospel  of  sanitation  among  the  people. 
Instead  of  becoming  alienated,  they  should  be  more  cooperative  in  all  that  tends  to 
lessen  human  suffering  and  lengthen  human  life.  Sanitation  or  preventive  medicine 
is  of  recent  growth,  but  in  this  country,  as  elsewhere,  like  all  new  enterprises,  has  had 
to  withstand  old  customs,  habits  and  ignorance  of  the  people,  from  whom,  under  our 
form  of  government,  all  laws  must  spring  and  be  sustained,  in  order  to  be  effective. 
The  prime  duty,  then,  of  health  officers  and  medical  men  is  to  educate  the  masses  as  to 
the  importance  of  statutes  providing  for  the  successful  application  of  all  measures  neces- 
sary for  the  removal  of  all  causes  operating  prejudicially  to  the  public  health. 

In  my  field  of  operation  as  county  health  officer,  I have  been  compelled  to  observe, 
•with  regret,  a large  measure  of  laggardness  and  indifference  in  sanitary  measures  among 
my  professional  brethren,  as  is  shown  by  their  neglect  in  reporting  the  existence  of 
infectious  disease,  as  urged,  as  well  as  in  many  other  things.  They  should  realize  that 
to  prescribe  sanitation  is  as  much  their  duty  as  to  prescribe  calomel,  and  that,  therefore, 
they  have  the  same  right  to  take  a fee.  It  does  not  follow,  therefore,  that  in  urging 
the  application  of  sanitary  principles,  they  necessarily  destroy  the  chances  for  income. 
If  so,  upon  the  same  principle  they  should  continue  to  keep  the  patient  sick.  The  doctor 
thrives  best  and  longest  who,  with  any  and  all  measures,  restores  his  patient  quickest. 
Such  considerations  of  selfishness  should  be  abandoned  by  them,  and  they  at  once  become 
leaders  in  sanitary  progress.  As  Hartshorne  remarks,  “practitioners  of  medicine  have 
need  to  be  thoroughly  versed  in  hygiene,  for  its  uses  in  the  treatment  of  their  patients, 
and  that  air,  water,  food,  sunlight  and  other  natural  agencies,  as  they  are  dealt  with, 
war  either  for  or  against  them.”  The  same  author  says  in  “Annals  of  Hygiene  :” — 

“One  cause  for  the  insufficient  interest  of  physicians,  so  far,  in  sanitary  science,  has 
been  the  general  absence  of  instruction  upon  hygiene  in  the  medical  schools.  Until 
the  University  of  Pennsylvania  established  a chair  of  hygiene,  for  a three  mouths’ 
course,  in  1886,  there  was,  except  a less  distinctly  professional  course  in  Harvard 


590 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


College,  nothing  of  the  kind  in  this  country.  In  hardly  any  other  medical  school 
in  the  United  States  is  there  to-day  more  than  a nominal  inclusion  of  hygiene,  under 
the  wing,  so  to  speak,  of  physiology.” 

This  ought  not  so  to  he  ; hygiene,  coming  naturally  between  physiology  and  path- 
ology on  the  one  hand  and  therapeutics  on  the  other,  ought  to  have  a full  place  in  every 
medical  curriculum.  It  should  be  granted  a professorship  to  itself,  in  the  winter  course, 
with  examinations  compulsory  for  every  graduate.  Only  when  this  is  done,  and  the 
whole  acquaintance  of  the  physician  with  the  subject  is  no  longer  postponed  till  after 
graduation,  then  to  he  picked  up  as  it  may  be  here  and  there,  only  then  will  it  he 
possible  for  the  members  of  the  medical  profession  fully  to  maintain  the  place  which  is 
theirs  of  right — that  of  thoroughly  equipped,  scientific  and  practical  leaders  in  sanitary 
progress. 

The  time  may  indeed,  and  ought  to,  come  when  sanitary  counsel  may  be  called  for 
and  professionally  given,  in  a manner  analogous  to  that  of  legal  advice,  to  prevent, 
instead  of  only  to  remedy,  disaster.  If  a careful  man  has  property  to  bequeath,  he 
consults  a lawyer  about  his  will.  When  he  has  a house  or  a farm  to  sell,  or  proposes 
to  buy  one,  a lawyer  or  conveyancer  inspects  the  title  and  sees  to  the  proper  and  safe 
conduct  of  the  transaction.  So,  why  should  not  the  family  sanitary  adviser  be  con- 
sulted about  the  situation,  construction,  drainage  and  ventilation  of  a proposed  new 
dwelling  to  be  built  or  bought  ? 

All  medical  colleges  should  set  the  example  by  establishing  regular  professorships 
on  public  hygiene,  and  thus  assume  a prominence  and  advantage  to  which,  in  the  nature 
of  their  calling,  they  are  justly  entitled. 

Not  only  in  medical  colleges  should  public  hygiene  be  taught,  but  also  in  the  uni- 
versities and  literary  colleges  of  the  country;  it  should  be  embraced  in  their  curricula. 
Systematic  and  thorough  text-books  upon  the  subject  should  be  introduced,  and  a faith- 
ful study  of  the  subject  be  enjoined  upon  the  pupil.  It  would  be  better  for  all  such 
institutions  to  employ  a thoroughly  educated  physician  and  practical  sanitarian  as  the 
instructor  and  lecturer  in  this  department,  and  at  the  same  time  supervise  and  direct 
the  sanitation  of  the  institution;  a subject  of  the  greatest  moment  to  schools,  where,  at 
the  tender  age  of  youth,  so  many  are  thrown  together.  Anatomy  and  physiology  have, 
to  a limited  extent,  been  taught  in  many  schools  for  years,  but  in  this  country  I have 
been  unable  to  learn  that  text-books  upon  hygiene  and  instruction  thereon  have  been 
added,  to  any  considerable  extent.  The  subject,  however,  here  and  there  seems  to 
have  received  some  attention.  In  a recent  letter  to  the  writer  from  Dr.  Henry  B. 
Baker,  Secretary  of  the  Michigan  State  Board  of  Health,  he  states  : — 

“ In  Michigan  we  have  for  some  time  had  lectures  on  sanitary  science  in  our  uni- 
versity, at  Hinsdale  College,  Albian  College  and  the  State  Agricultural  College.  Some 
of  our  high  schools  are  becoming  interested  in  the  subject.  ” As  a further  means  of 
enlightenment,  leading  universities  of  different  States  could  not  do  better  than  to  imitate 
the  energy,  intelligence  and  liberality  of  Michigan,  by  securing  in  some  way  the  means 
necessary  to  establish  a laboratory  of  hygiene  and  physics.  He  says,  1 ‘ We  are  now 
breaking  ground  for  a thirty  thousand  dollar  building  in  Anu  Arbor,  which  will  be 
given  up  to  the  laboratory  of  hygiene  and  the  laboratory  of  physics.  Five  thousand 
dollars  have  been  appropriated  for  their  equipment.  ” While  in  European  countries 
such  laboratories  are  numerous,  in  the  United  States,  perhaps,  there  are  none,  except 
at  the  University  of  Harvard,  John  Hopkins  University,  and  prospectively  at  Ann  Arbor. 

Public  Schools. — Another  means  for  further  and  more  rapid  and  effective  diffusion 
of  a knowledge  of  hygiene  would  be  to  teach  it  in  the  public  and  private  schools  of  the 
country,  especially  to  the  advanced  classes.  Latin,  Greek,  Hebrew,  Algebra,  Rhetoric, 
Logic,  High  Art  and  Music  and  many  other  things  are  taught  in  such  schools,  that  in 
after  life  are  found  to  be  comparatively  useless  to  the  masses  in  their  struggles  for 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  591 


bread.  Could  not  a knowledge  of  hygiene  be  imparted  in  these  schools,  by  systematic 
teaching,  which  in  the  serious  march  of  life  would  he  equally  if  not  far  more  import- 
ant? Is  it  not  as  practicable  to  instill  a knowledge  of  hygiene  into  the  minds  of  pupils 
as  that  of  dead  languages,  philosophy  or  political  economy  ? Is  it  more  valuable  or 
productive  of  more  happiness  to  possess  a knowledge  of  belles-lettres  than  to  under- 
stand how  the  human  body  is  dependent  upon,  and  affected  for  life  or  death  by,  sur- 
rounding elements  and  conditions?  Is  a knowledge  of  logarithms,  trigonometry,  or  cal- 
culus more  conducive  to  health  and  wealth  than  a knowledge  of  house  construction, 
home  sanitation,  or  prevention  of  epidemics  ? I would  not  be  understood  as  underrat- 
ing the  knowledge  acquired  by  pursuing  the  usual  curricula  of  our  schools,  but  sub- 
mit that  the  minds  which  grapple  so  successfully  with  their  intricate  and  ornamental 
problems  can  as  easily  and  with  far  more  practical  advantage  master  the  principles  of 
sanitary  science. 

According  to  the  census  of  the  United  States,  in  1880  there  were  attending  the  vari- 
ous schools  of  the  country  9,946,160  pupils.  Suppose  this  number,  or  even  half,  with 
graded  and  suitable  text-books,  were  being  instructed,  as  in  other  studies,  in  the  princi- 
ples of  hygiene;  who  could  compute  the  wonderful  revolution  that  would  inevitably 
follow  upon  the  subject  of  public  health,  within  a dozen  years,  in  this  country?  What 
a diffusion  of  knowledge  and  influence  for  good  would  be  wrought  all  over  the  land  as 
they  would  enter  upon  the  pursuits  of  life  ! What  more  potent  method  could  be 
adopted  for  the  dissipation  of  the  incubus  of  ignorance  which  prevails  as  to  the  anatomy, 
physiology  and  hygiene  of  the  human  body?  I once  asked  an  intelligent  lawyer,  as  we 
were  viewing  a manikin,  to  point  to  the  place  where  he  thought  the  stomach  was. 
Placing  his  finger  on  top  of  the  sternum,  he  said,  1 ‘ There,  there  it  is.  ” I replied,  “You 
are  mistaken.”  “Well,”  said  he,  “there  is  where  I feel  sick  when  I puke.”  As 
truthfully  remarked  by  the  Rev.  J.  L.  Patton,  of  Michigan,  “There  is  scarcely  any 
subject  of  human  knowledge  of  which  the  mass  of  men  know  so  little,  as  their  own 
proper  selves.”  It  is  hard  to  illustrate.  Here  is  a man  of  mature  years,  who,  when 
asked  the  other  day  what  the  thorax  is,  said  that  it  is  a big  vein  that  runs  down  the 
backbone.  But  that  man  is  a practicing  surgeon,  had  performed  an  autopsy  on  the 
body  of  a murdered  woman,  and  made  this  answer  on  the  witness  stand  of  the  Circuit 
Court.  What,  then,  must  be  the  condition  of  laymen  ? 

Further,  it  is  said — and  there  is  a good  show  of  authority  for  it— that  knowledge 
is  power.  George  Eliot  asks  why  nobody  ever  speaks  of  the  power  of  ignorance. 
Ignorance  is  not  properly  power.  It  cannot  tunnel  a mountain ; it  is  the  mountain  to 
be  tunneled,  that  lies  in  the  way  of  every  proper  accomplishment  by  power.  It  is  weak- 
ness to  the  mind  and  weakness  and  death  to  the  body.  This  ignorance  of  men  in  mass 
as  to  the  anatomy  of  their  own  persons,  and  of  the  physiology  and  hygiene  pertaining 
thereto,  means  ignorance  of  the  laws  of  health,  and  their  consequent  violation  and 
penalty.  Sanitary  reform  will  make  no  headway  worth  mention  through  such  igno- 
rance. It  is  not  enough  that  some  physicians  and  a few  experts  and  specialists  be 
intelligent  as  to  sanitary  science.  The  people  will  not  gather  themselves  up  and  do 
these  things  merely  because  they  are  told  that  this  will  be  best  for  them.  To  the  end 
that  they  may  live  long  and  to  best  purpose— the  object  to  be  attained — people  must 
themselves  become  intelligent  as  to  how  to  build  their  homes  and  cities,  how  to  eat  and 
how  to  sleep,  how  to  work  and  how  to  rest,  how  to  keep  the  earth  clean  where  they  are, 
and  the  air,  and  the  water,  also  themselves  and  everything  about  them.  They  must 
know  how  best  to  keep  up  the  wholesome  balance  between  the  activities  of  the  physical 
man  and  those  of  the  mind.  They  must  also  know  how  best  to  keep  every  part  of  their 
own  animal  economy  at  its  own  proper  work  and  fully  up  to  the  requirements  upon  it 
of  the  whole  man.  They  must  also  see  how  these  things  are  necessary.  All  this  may 
be  the  work,  properly,  of  the  common  schools  of  the  land,  but  it  is  the  province  of 


592 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


sanitarians  to  call  for  it.  If  our  boys  and  girls,  at  the  age  of  sixteen  years,  could  chart 
the  arterial  and  venous  systems  of  the  human  body,  and  have  sufficient  knowledge  of 
its  functions  and  hygiene,  they  could  well  afford  to  be  ignorant  of  the  river  systems  of 
Europe,  Asia  and  Africa;  and  if  they  could  also  have  knowledge  of  the  nervous  system, 
the  system  of  digestion  and  nutrition,  the  respiratory  system,  and  the  mechanics  of  the 
bones,  with  their  several  functions  and  hygiene,  they  could  afford,  even  as  a means  of 
mental  discipline,  to  leave  out  the  rest  of  their  geography,  their  definitions  of  dictionary 
words  and  part  of  their  mathematics.  This  would  give  foundation  for  sanitary  reform 
such  as  might,  in  time,  bring  human  life  up  to  its  natural  duration  of  a hundred 
years. 

In  a recent  letter  from  Dr.  Ezra  M.  Hunt,  Secretary  of  the  State  Board  of  Health, 
New  Jersey,  and  teacher  of  hygiene  in  the  Normal  School  at  Trenton,  he  says,  with 
reference  to  teaching  hygiene  in  the  public  schools  : “I  have  thought  much  upon  the 
subject  upon  which  you  speak,  and  have  the  conviction  that  we  will  not  reach  great 
reforms  in  the  care  of  public  health  until  our  children  are  taught  in  the  schools  what 
are  the  conditions  of  health.  This  will  not  come  by  the  mere  teaching  of  physiology. 
We  must  directly  teach  hygiene.  ” “ One  of  the  first  things  is  to  teach  teachers.  ” “I 

do  not  believe  any  text-book  takes  the  place  of  a teacher.”  “My  own  classes  enjoy 
it  as  much  as  any  study  they  have,  and  get  out  of  it  science  and  mental  training,  as 
well  as  practical  facts.” 

In  view,  therefore,  of  the  benefits  to  be  derived  from  a diffused  knowledge  of  hygiene, 
may  it  not  be  pertinently  suggested  that  sanitarians  throughout  the  land  arouse  them- 
selves to  increased  efforts  to  have  the  subject  embraced  in  the  curricula  of  the  schools, 
and  advise  the  teaching  of  the  subject  be  intrusted  to  thoroughly  competent  physicians 
and  practical  sanitarians?  In  this  way  there  will  be  indelibly  impressed  upon  the 
minds  of  youth  valuable  facts  pertaining  to  the  conservation  of  health,  which  is,  indeed, 
individual,  as  well  as  public  wealth. 

Should  this  paper  contribute  in  any  wise  to  the  agitation,  or  adoption,  by  the  various 
school  authorities  of  the  land,  of  the  views  herein  imperfectly  presented,  then  would  I 
feel  conscious  that  having  thus  complied  with  an  invitation  to  write  upon  the  subject 
of  Public  Hygiene  for  the  Ninth  International  Medical  Congress  my  labor  had  not 
been  wholly  in  vain. 

DISCUSSION. 

Dr.  Benjamin  Lee,  after  commending  the  paper  of  Dr.  Cook,  offered  the  fol- 
lowing resolutions,  which  were  unanimously  adopted  : — 

Resolved. , That  this  Section  cordially  endorses  the  suggestions  contained  in  the 
paper  of  Dr.  Cook,  of  Nashville,  “On  the  necessity  for  teaching  hygiene  in  schools,  ” 
and  recommends  to  the  Congress  the  passage  of  the  following  resolutions : — 

Resolved , That  it  is  the  sense  of  the  Fifteenth  Section, Public  and  International 
Hygiene,  of  the  Ninth  International  Medical  Congress — 

1.  That  every  medical  college  should  place  the  chair  of  hygiene  in  its  curriculum, 
and  on  an  equal  footing  with  the  other  regular  branches  of  instruction. 

2.  That  in  all  universities,  colleges  and  high  schools,  hygiene  should  form  a part 
of  the  compulsory  course  of  study,  and  should  be  taught,  not  simply  by  text-books, 
but  by  educated  physicians. 

3.  That  in  all  public  schools  the  teaching  of  hygiene  should  form  a prominent 
and  essential  feature. 

4.  That  every  State  Legislature  should  establish  a museum  and  laboratory  of 
hygiene. 

5.  That  these  resolutions  be  transmitted  to  the  Ninth  International  Medical 
Congress,  in  general  session,  for  its  action  and  endorsement. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  593 


Dr.  11.  C.  Davis,  of  Seneca,  S.  C. — I wish  to  express  my  heartfelt  thanks  to  the 
gentleman  for  this  paper.  This  is  a grand  and  all-important  subject.  We  all  agree 
that  hygiene  should  he  taught  in  all  medical  colleges,  and  also  in  universities,  col- 
leges and  common  schools.  How  we  can  attain  this  object  is  the  question.  How 
can  we  induce  those  having  power  to  take  the  proper  steps  to  have  it  taught  in  all 
schools.  We  should  recommend  it,  as  a Section,  and  as  a Grand  International  Medi- 
cal Congress.  I wish  to  second  the  resolutions  offered,  recommending  such  a course 
of  instruction  in  all  schools  and  colleges. 

The  President  of  the  Fifteenth  Section  placed  in  the  hands  of  Dr.  N.  S.  Davis, 
President  of  the  Ninth  International  Congress,  the  foregoing  resolutions  of  Di\ 
Benjamin  Lee,  for  the  formal  consideration  and  action  of  the  Congress. 


A NEW  METHOD  OF  TESTING  THE  GERMICIDAL  AND  ANTISEPTIC 
POWERS  OF  CERTAIN  MINERAL  AND  VEGETABLE  SUBSTANCES 
EMPLOYED  EXTERNALLY  AND  INTERNALLY  IN  THE  TREAT- 
MENT OF  WOUNDS,  TUMORS,  ENLARGED  GLANDS,  ULCERS 
AND  SYPHILIS ; AND  IN  CERTAIN  SANITARY  OPERATIONS  OF 
DOMESTIC  AND  PUBLIC  HYGIENE. 

ITNE  METIIODE  POUR  EPROUVER  LE  POUVOIR  GERMICIDE  ET  ANTISEPTIQUE 
DE  CERTAINES  SUBSTANCES  MINERALES  ET  VEGETALES  DANS  LE  TRAITE- 
MENT  EXTERIEUR  ET  INTERIEUR  DES  BLESSURES,  TUMEURS,  RENFLEMENT 
DES  GLANDES,  ULCERES  ET  SYPHILIS  j ET  DANS  CERTAINES  OPERATIONS 
SANITAIRES  D’HYGIENE  PUBLIQUE  ET  DOMESTIQUE. 

UBER  EINE  NEUE  METHODE  ZUR  PRUFUNG  DER  GERMICIDEN  UND  ANTISEPTISCHEN 
KRAFTE  GEWISSER  MINERALISCHER  UND  V EG  ETA  BILISCHER  SUBSTANZEN,  WELCHE 
AUSSERLICH  UND  INNERLICH  IN  DER  BEHANDLUNG  VON  WUNDEN,  GESCHWULSTEN, 
GESCIIWOLLENEN  DRUSEN,  GESCHWUREN  UND  DER  SYPHILIS,  UND  IN  GEWISSEN 
SANITAREN  VERPJCHTUNGEN  DER  HAUSLICHEN  UND  OFFENTLICHEN  HYGIENE 
ANGEWANDT  WERDEN. 


BY  JOSEPH  JONES,  M.D., 
New  Orleans,  La. 


GENERAL  OBSERVATIONS  ON  PUTREFACTION  AND  ZYMOSIS,  ILLUSTRATING  THE 
PRESENT  STATE  OF  SANITARY  SCIENCE. 

The  access  of  air,  together  with  a moderate  amount  of  warmth  and  of  moisture,  are 
necessary  to  the  occurrence  of  the  putrefactive  changes  which  consist  essentially  in  the 
breaking  up  of  the  complex  organic  material  and  the  formation  of  new  and  simpler 
combinations  among  its  constituent  elements.  During  the  process  various  vapors  and 
gases  are  evolved,  and  the  lower  forms  of  animal  and  vegetable  life  are  observed  to 
grow  and  multiply  in  the  putrefying  substance.  The  exciting  causes  of  putrefaction 
have  long  formed  a subject  of  scientific  discussion,  two  widely  different  theories  hem" 
maintained  respecting  them.  By  the  one,  the  changes  which  occur  during  the  process 
are  held  to  be  from  the  first  the  result  of  chemical  decomposition  in  the  organic  sub- 
stance, whose  atoms  are  in  a state  of  motion  or  activity,  which  is  capable  of  being  com- 
municated by  catalytic  action  to  other  organic  material  in  contact  with  it  (Liebig); 
while,  further,  it  is  asserted  that  minute  living  organisms  may  be  evolved  from  the 
dead  material  as  the  result  of  these  chemical  transformations. 

Vol.  IV— 38. 


594 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


By  the  other  theory,  which  is  founded  mainly  upon  the  researches  of  Pasteur,  the 
putrefactive  changes  are  ascribed  to  the  agency  of  organized  germs  ever  present  in  the 
atmosphere,  which,  finding  a suitable  nidus  in  the  putreseible  material,  grow  and  mul- 
tiply, producing  the  chemical  decompositions  as  the  result  of  their  action.  Putrelaction, 
it  is  further  maintained,  may  be  entirely  prevented  by  means  which  exclude  the  access 
of  germs.  The  subject  derives  much  interest  and  importance  from  its  relation  to  the 
doctrines  of  the  origin  of  life,  as  well  as  to  questions  concerning  the  sources  of  contagion 
,and  epidemic  disease,  and  continues  to  the  present  time  a matter  of  keen  inquiry  and 
experiment  among  physiologists.  Various  opinions  are  entertained  regarding  the 
modus  operandi  of  antiseptics.  By  those  who  hold  the  purely  chemical  theory  of  putre- 
faction they  are  believed  to  operate  in  different  ways,  according  to  their  chemical  pro- 
perties ; thus,  sulphurous  acid  is  said  to  act  by  deoxidizing  the  putreseible  matter;  the 
mineral  acids  and  metallic  salts  by  combining  with  the  substance,  and  forming  a per- 
manent compound  ; and  the  tar  acids  in  a similar  manner.  On  the  other  hand,  the 
supporters  of  the  germ  theory  maintain  that  carbolic  acid,  and  indeed  all  true  antisep- 
tics, produce  their  effect  by  acting  as  poisons  to  the  infusorial  organisms  which  are  held 
to  be  essential  to  the  occurrence  of  the  putrefactive  process. 

We  accept  the  preceding  facts  and  statements  of  the  theories  with  reference  to  the 
origin  of  diseased  germs  without  further  comment,  and  proceed  at  once  to  the  detail  of 
the  results  of  our  investigations. 

SCOPE  OF  THE  PRESENT  INQUIRY. 

It  is  of  importance  that  the  relative  value  of  the  agents  used  in  the  local  and  con- 
stitutional treatment  of  wounds,  tumors  and  ulcers,  contagious  diseases,  as  syphilis, 
should  be  determined  by  well-devised  and  easily  manipulated  and  comprehensive 
experiments.  If  certain  diseases  be  caused  by  microorganisms,  bacteria  and  fungi,  it  is 
of  importance  to  the  physician  and  surgeon  that  the  relations  of  the  therapeutic  agents 
to  the  pathogenic  organisms  should  be  carefully  and  thoroughly  determined.  Inves- 
tigations upon  the  relations  of  disinfectants  and  antiseptics  demand  the  most  profound 
and  protracted  investigation  with  the  higher  powers  of  the  microscope,  and  more  or  less 
obscurity  necessarily  attaches  to  results  thus  obtained.  Besides,  it  is  important  to 
demonstrate  the  results  beyond  cavil  to  those  unacquainted  with  the  use  of  the  micro- 
scope. Science  demands  a method  of  research  at  once  simple  and  open  to  the  obser- 
vation of  the  naked  eye,  and  to  all  observers,  whether  skilled  or  not  in  the  use  of  the 
microscope;  only  those  who  have  labored  for  any  length  of  time  in  the  field  of  bacteri- 
ology with  the  higher  powers  of  the  microscope  can  form  any  accurate  judgment  as  to 
the  effect  of  the  continual  strain  upon  the  organs  of  vision.  If  there  be  any  tendency 
to  inflammation  of  the  eyes  or  to  neuralgic  hemicrania,  great  suffering,  if  not  irreparable 
damage  of  the  eyes,  may  result. 

In  order  to  determine  experimentally  the  relative  value  of  the  agents  employed 
locally  and  internally  in  the  treatment  of  wounds,  ulcers  and  of  syphilitic  affections,  in 
such  a manner  as  to  omit  tedious  and  doubtful  labors  with  the  higher  powers  of  the 
microscope,  it  was  necessary  to  select  the  larger  germs,  whose  evolution  could  be 
observed  by  the  naked  eye.  Of  course,  such  a line  of  experiment  was  applicable  to  all 
medical  agents  and  poisons,  whether  or  not  included  under  the  divisions  of  antiseptics 
or  disinfectants. 

METHOD  OF  EXPERIMENTS  WITH  POISONS,  ANTISEPTICS  AND  DISINFECTANTS. 

The  plant  selected  for  these  experiments  was  rice  (Oriza  sativa).  If  grains  of  rice 
be  placed  in  water,  they  will,  if  the  water  be  of  the  proper  temperature,  germinate,  and 
the  plants  will  grow  several  inches  in  water  without  the  addition  of  any  extraneous 
matter.  During  the  period  of  the  germination  and  growth  of  the  rice,  we  have  a favor- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


595 


able  opportunity  of  testing  the  effects  of  various  poisons,  simply  by  adding  them  to  the 
water.  It  will  be  of  some  interest  to  consider  briefly  the  history  and  nature  of  the 
plants  which  we  have  selected  for  this  series  of  experiments. 

Bice,  Oriza  saliva — General  Observations. — Rice  has  been  known  and  cultivated  from 
the  earliest  records  of  the  human  race,  and  it  is  believed  to  furnish  food  for  a greater 
number  of  human  beings  than  any  other  of  the  cultivated  cereals.  Of  this  plant  there 
has  usually  been  held  to  be  but  one  species — Oriza  sativa,  common  rice.  But  there  are 
sub-species  or  varieties,  so  greatly  different  in  their  habits  and  characters  that  they  may 
be  rather,  perhaps,  regarded  as  specifically  distinct.  They  may  be  all  referred  to  two 
general  types — the  common  rice,  so  termed,  and  the  mountain  rice,  Oriza  mutica  of 
many  botanists,  which  differs  from  the  other  in  its  general  aspect  and  habits. 

The  common  rice  grows  from  one  to  six  feet  in  height,  terminating  in  a pinnacle, 
the  seeds  of  which  are  armed  with  long  arms.  It  is  cultivated  in  marshes,  aud  for  a 
great  part  of  its  growth  is  partially  under  water.  The  mountain  rice  grows  on  moun- 
tains aud  dry  soils.  A plant  of  this  class  has  been  recently  found  growing  high  on  the 
range  of  the  Himalayan  mountains.  The  rice  is  spread  over  all  the  warmer  regions  of 
the  Old  World,  and  has  been  carried  to  the  New,  where  it  flourishes  in  great  luxuriance. 
The  common  rice  is  cultivated  in  the  south  of  Europe,  and  the  mountain  rice  has  lately 
been  extended  to  the  more  northern  parts  of  it,  to  Westphalia,  and  even  to  the  Low 
Countries.  Rice  seems  to  be  a plant  fitted  in  a remarkable  degree  to  accommodate 
itself  to  different  situations.  It  is  a considerable  period  since  it  was  introduced  into 
the  countries  north  of  the  Mediterranean,  Greece,  Italy  and  Spain.  It  is  more  recently 
that  it  has  extended  to  Hungary  and  Central  Europe. 

Historical  Notes  on  the  Cultivation  of  Bice. — Rice,  according  to  the  testimony  of  botan- 
ical and  agricultural  writers,  has  been  cultivated  from  time  immemorial  in  tropical  coun- 
tries. The  fact  of  its  having  been  used  in  a Chinese  ceremonial  as  early  as  2800  years  B.  c. , 
induced  Alphonse  de  Candolle  to  consider  rice  as  a native  of  China.  It  was  very  early 
cultivated  in  India,  in  some  parts  of  which  country,  as  in  tropical  Australia,  it  is,  as  we 
have  seen,  indigenous.  It  is  not  mentioned  in  the  Bible,  but  its  culture  is  alluded  to  in 
the  Talmud.  There  is  no  evidence  of  the  existence  of  rice  in  Egyptian  remains,  nor  is 
there  any  trace  of  it  as  a native  plant  among  the  Greeks,  Romans  or  ancient  Persians. 
There  is  proof  of  its  culture  in  the  Euphrates  valley  and  in  Syria,  400  years  before 
Christ.  Crawford,  on  philological  grounds,  considers  that  rice  was  introduced  into 
Persia  from  southern  India.  The  Arabs  carried  the  plant  into  Spain  under  the  name 
‘‘aruz,  ” the  arros  of  the  Spanish,  the  rizo  of  the  Italian,  whence  our  word  rice. 

Rice  was  first  cultivated  in  Italy,  near  Pisa,  in  1468.  It  was  not  introduced  into 
Carolina  until  1700,  and  then,  as  it  is  said,  by  accident,  although  at  one  time  the 
southern  United  States  furnished  a large  proportion  of  the  rice  introduced  into  com- 
merce. Rice,  says  Crawford,  sports  into  far  more  varieties  than  any  of  the  corns 
familiar  to  Europeans,  for  some  varieties  grow  in  the  water  and  some  on  dryland; 
some  come  to  maturity  in  three  months,  while  others  take  four  and  six  months  to  do  so. 
The  Hindus,  however,  are  not  content  with  such  broad  distinctions  as  might  be  derived 
from  these  obvious  sources,  but  have  names  for  varieties,  the  distinctions  between 
which  are  unapplicable  by  Europeans;  besides  terms  for  this  corn  founded  on  variety 
on  season,  and  on  mode  of  culture,  the  grain  itself  bears  one  name  in  the  straw,  another 
when  threshed,  one  name  in  the  husk  and  another  when  freed  from  it,  and  a fifth  when 
cooked.  A similar  abundance  of  terms  is  found  in  the  languages  of  the  Malay  and 
Philippine  islands.  Such  minute  nomenclatures  seem  to  point  to  a great  antiquity  in 
the  culture  of  this  cereal. 

Botanical,  Microscopical  and  Chemical  Characters  of  Bice,  and  its  Nature  as  an  Article 
of  Food. — According  to  Roxburgh,  the  cultivated  rice,  with  all  its  numerous  varieties, 
has  originated  from  a wild  plant,  called  in  India  newaree,  or  nivara  (Oriza  sativa).  It 


59G 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


is  said  to  grow  on  the  borders  of  lakes  in  the  Circars  and  elsewhere  in  India,  and  is 
also  native  in  tropical  Australia.  The  rice  plant  is  an  annual  grass  with  long,  glab- 
rous leaves,  each  provided  with  a long,  sharply-pointed  ligule.  The  spikelets  are 
borne  on  a compound  or  branched  spike,  erect  at  first,  but  afterward  bent  downward. 
Each  spikelet  contains  a solitary  flower  wilh  two  outer  small  glumes  and  two  inner, 
larger  and  folded  lengthwise,  the  outer  one  of  the  two  rather  larger  and  sometimes 
provided  with  an  arm.  Within  these  are  six  stamens,  a hairy  ovary,  surmounted  by 
two  feathery  styles  which  ripen  into  the  fruit  (grains),  and  which  is  invested  by  the 
husk  formed  by  the  persistent  glucess.  The  cultivated  varieties  are  extremely  numer- 
ous, some  kinds  being  adapted  for  marshy  land,  others  for  growth  on  the  hill  sides. 
The  cultivators  make  two  principal  divisions,  according  as  the  sorts  are  early  or  late. 
Other  subdivisions  depend  upon  the  habit  of  the  plant,  the  presence  or  absence  of  an 
arm,  the  color  of  the  grain  and  other  particulars.  Rice  constitutes  one  of  the  most 
important  articles  of  food  in  all  tropical  and  sub-tropical  countries,  and  is  one  of  the 
most  prolific  of  all  crops.  The  rice  yields  best  on  low  lands  subject  to  occasional  inun- 
dations, and  thus  enriched  by  alluvial  deposits.  An  abundant  rainfall  during  the  grow- 
ing season  is  also  a desideratum.  Rice  is  sown  broadcast,  and  in  some  districts  is  trans- 
planted after  a fortnight  or  three  weeks.  No  special  rotation  is  followed;  indeed,  the 
soil  best  suited  for  rice  is  ill  adapted  for  any  other  crop.  In  some  cases  little  manure 
is  employed,  but  in  others  abundance  of  manure  is  used.  No  special  tillage  is  required, 
but  weeding  and  irrigation  are  requisite.  Rice  in  the  husk  is  known  as  “paddy.”  In 
cutting  across  a grain  of  rice  and  examining  it  under  the  microscope,  first  the  flattened 
and  dried  cells  of  the  husk  are  seen,  and  then  one  or  two  layers  of  cells  elongated  in  a 
direction  parallel  to  the  length  of  the  seed,  which  contains  the  gluten  or  nitrogenous 
matter.  Within  these,  and  forming  by  far  the  largest  part  of  the  seed,  are  large  poly- 
gonal cells  filled  with  numerous  and  very  minute  angular  starch  grains.  Rice  is  not  so 
valuable  as  afood  as  some  other  cereals,  inasmuch  as  the  proportion  of  nitrogenous  matter 
(gluten)  is  less.  Payen  gives  only  seven  per  cent,  of  gluten  in  rice  as  compared  with 
22  per  cent,  in  the  finest  wheat,  15  in  oats  and  12  in  maize.  The  percentage  of  potash 
in  the  ash  is  as  18  to  23  in  wheat.  The  fatty  matter  is  also  less  in  proportion  than  in 
other  cereals.  Rice,  therefore,  is  chiefly  a farinaceous  food,  and  requires  to  be  com- 
bined with  fatty  and  nitrogenous  substances,  such  as  milk  or  wheat  gravy,  to  satisfy 
the  requirements  of  the  system. 

EXPERIMENTS  ILLUSTRATING  THE  EFFECTS  OF  CERTAIN  POISONS,  GERMICIDES,  ANTI- 
SEPTICS AND  DISINFECTANTS  UPON  THE  GERMINATION,  GROWTH  AND  PRESER- 
VATION OF  THE  SEEDS  OF  RICE  (ROUGH  RICE). 

Experiments  wiili  Hydrogen  and  Potassic  Cyanide. — 1st  Scries.  Experiments  upon  the 
Action  of  Prussic  Acid  ( Hydrocyanic  Acid ) and  Cyanide  of  Potassium  upon  Plants  (Rice.  Oriza 
sativa),  at  Maybanlc,  Georgia,  in  the  summer  of  1S54- 

Experiment  1. — Hydrocyanic  acid  was  added  to  half  a fluidounce  of  spring  water, 
in  which  the  rice  seeds  had  been  placed,  in  an  open  glass  vessel.  The  hydrocyanic  acid 
retarded  germination  for  several  days,  but  did  not  arrest  the  final  development  of  the 
young  plants.  The  degree  of  retardation  was  determined  by  conducting  simultaneously 
experiments  with  rice  and  pure  water. 

Experiment  2. — Action  of  Hydrocyanic  Acid  upon  Rice  in  Closed  Vessels. 

When  the  rice  seeds  and  dilute  solutions  of  prussic  acid  were  put  in  a partially  cov- 
ered glass  vessel,  with  sufficient  atmospheric  air  for  germination,  they  did  not  ger- 
minate. When  the  grains  were  removed  from  this  solution,  with  very  few  exceptions, 
they  were  incapable  of  germination,  although  originally  perfect.  The  experiments 
were  performed  in  the  month  of  Juue,  in  an  upper,  well-ventilated  room,  where  the 


SECTION  XV — rUBLIC  AND  INTERNATIONAL  HYGIENE.  597 


temperature  and  light  were  most  favorable  for  a rapid  and  vigorous  germination  and 
growth,  and  were  repeated  upon  more  than  one  hundred  grains  of  riee. 

If  we  compare  the  two  experiments  and  consider  the  surrounding  circumstances,  it 
is  evident  that  the  different  results  were  due  to  the  fact  that  when  the  rice  was  subjected 
to  the  action  of  dilute  prussic  acid  in  open  vessels,  the  poison,  from  its  volatile  nature, 
was  evaporated,  in  a great  measure,  before  it  produced  any  deleterious  effects  upon  the 
rice;  in  the  confined  space,  on  the  other  hand,  while  the  seeds  had  all  the  essential  con- 
ditions of  germination,  viz.,  heat,  moisture  and  a sufficient,  if  not  abundant,  supply  of 
oxygen  in  the  confined  air,  still,  the  absorption  of  the  prussic  acid  continued  unimpeded 
and  arrested  the  process  of  germination  in  its  earliest  stages,  for  the  seeds,  in  almost 
every  instance,  presented  upon  the  exterior  an  unaltered  appearance. 

Experiment  3. — Action  of  Hydrocyanic  Acid  upon  Germiuated  and  Growing  Rice. 

When  dilute  hydrocyanic  acid  was  added  to  the  water  in  which  the  young  shoots 
were  growing,  it  arrested  the  growth  and  caused  death  in  periods  of  time  corresponding 
with  the  amount  of  acid  added.  This  experiment  was  repeated  upon  more  than  one 
hundred  stalks  of  growing  rice,  with  similar  results. 

Second  Series.  Action  of  Cyanide  of  Potassium  upon  Plants. — In  the  experiments  with 
this  salt,  as  well  as  in  those  of  hydrocyanic  acid,  rice  was  the  plant  selected,  and  the  sur- 
rounding conditions  of  temperature  were  the  same. 

Experiment  4. — Action  of  Cyanide  of  Potassium  upon  the  Germination  of  Rice. 

Both  in  closed  and  uuclosed  vessels,  solutions  of  cyanide  of  potassium  arrested  com- 
pletely the  process  of  germination.  The  word  arrested  is  here  used  because  it  is  diffi- 
cult in  such  experiments  to  affirm  that  not  a single  change  took  place  in  the  organic 
elements  before  the  complete  arrest  of  the  process.  It  is  certain,  however,  that  if  any 
of  the  numerous  changes  of  germination  took  place,  they  did  not  proceed  far  when  the 
seeds  thus  acted  upon  by  cyanide  of  potassium  were  transferred  to  pure  water.  In  no 
instance  did  germination  take  place,  they  simply  underwent  slow  decay.  This  experi- 
ment was  repeated  with  the  same  result  upon  more  than  one  hundred  rice  seeds.  Cor- 
responding experiments  were  carried  on  at  the  same  time  with  pure  water. 

Experiment  5. — Action  of  Cyanide  of  Potassium  upon  Growing  Rice. 

Solutions  of  cyanide  of  potassium  in  every  instance  arrested  the  growth  and  caused 
the  death  of  the  growing  rice;  and  the  rapidity  of  its  action  corresponded  with  the 
amount  of  the  poison  added.  These  experiments  were,  in  like  manner,  repeated  upon 
more  than  one  hundred  stalks  of  growing  rice.  The  following  conclusions  may  be 
drawn  from  the  preceding  experiments  : — 

1.  Plants  as  well  as  animals  may  be  destroyed  by  certain  mineral  and  vegetable 
substances  denominated  poisons. 

2.  As  the  vegetable  kingdom  is  without  nerves,  muscles,  or  any  special  circulating 
apparatus  similar  to  the  automatic  apparatus  of  animals,  it  is  evident  that  these  poi- 
sons must  act  upon  the  individual  living  cells  composing  the  vegetables. 

3.  As  the  living  component  cells  of  the  vegetable  kingdom  are  capable  of  elaborating 
distinct  products  from  the  surrounding  nutritive  materials,  and  as  this  power  is 
destroyed  by  poisons,  we  must  conclude  that  the  functions  of  secretion,  growth  and 
nutrition  may  be  influenced  directly  by  poisons,  without  the  intervention  of  the  ner- 
vous system. 

4.  As  therefore  poisons  may  act  directly  upon  the  individual  living  cells  of  vege- 
tables, arresting  the  process  of  the  acts  of  germination  in  the  seed,  and  of  the  acts  of 
secretion,  nutrition  and  growth  in  the  fully-formed  cells;  it  is  reasouable  to  infer  that 
poisons  may  act  upon  the  individual  living  cells  of  animals.  Thus  poisons  may  act 
directly  upon  the  muscular  fibres,  or  upon  the  ganglionic  cells  of  the  sympathetic  and 
cerebro-spinal  system,  or  upon  the  secreting  and  excreting  cells  of  the  liver  and  kidneys, 
or  upon  the  colored  and  colorless  corpuscles  of  the  blood. 


598 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


EXPERIMENTS  ILLUSTRATING  THE  RELATION,  POWERS  AND  EFFECTS  OF  CERTAIN 
ANTISEPTICS,  DISINFECTANTS  AND  GERMICIDES. 

Definition  of  terms,  and  a general  outline  of  the  present  state  of  our  knowledge 
with  reference  to  disinfectants  and  antiseptics  appear  to  be  a useful  introduction  to  the 
following  experiments: — 

Definition  of  Terms  and  Brief  Outline  of  Established  Facts  Relative  to  Disinfectants 
and  Antiseptics. — Disinfectants  are  agents  or  substances  employed  to  prevent  the  spread 
of  contagious  or  infectious  diseases.  Recent  investigations  all  tend  to  demonstrate  that 
the  efficiency  of  any  disinfectant  is  due  to  its  power  of  destroying,  or  rendering  inert, 
specific  poisons  or  disease  germs  which  possess  in  themselves  an  independent  existence, 
and  which,  when  introduced  into  the  animal  system  under  favorable  conditions,  increase 
and  multiply,  thus  producing  the  phenomena  of  special  diseases.  Therefore,  antisep- 
tic substances  generally,  which  check  or  stop  putrefactive  decay  in  organic  compounds, 
by  preventing  the  growth  of  these  minute  organisms  which  produce  putrefaction,  are 
on  that  account  disinfectants.  So  also  the  deodorizers,  which  act  by  oxidizing  or 
otherwise  changing  the  chemical  constitution  of  volatile  substances  disseminated  in  the 
air,  or  which  prevent  noxious  exhalations  from  organic  substances,  are,  in  virtue  of 
these  properties,  effective  disinfectants  in  certain  diseases.  A knowledge  of  the  value 
of  disinfectants,  and  the  use  of  some  of  the  most  valuable  agents,  can  be  traced  to  very 
remote  times;  and  much  of  the  Levitical  law  of  cleansing,  as  well  as  the  origin  of 
numerous  heathen  ceremonials  and  practices,  are  clearly  based  on  a perception  of  the 
value  of  disinfection.  The  means  of  disinfection  and  the  substances  employed  are 
very  numerous,  as  are  the  classes  and  conditions  of  disease  and  contagion  they  are 
designed  to  meet.  Nature,  in  the  oxidizing  influence  of  freely  circulating  atmospheric 
air,  in  the  purifying  effect  of  water,  and  in  the  powerful  deodorizing  properties  of  com- 
mon earth,  has  provided  the  most  potent,  ever-present  and  acting  disinfecting  media. 

Of  the  artificial  disinfectants  employed  or  available,  three  classes  may  be  recog- 
nized : — 

1.  Volatile  or  vaporizable  substances  which  attack  impurities  in  the  air. 

2.  Chemical  agents  for  acting  on  the  diseased  body  or  on  the  infectious  discharges 
therefrom  ; and 

3.  The  physical  agencies  of  heat  and  cold. 

In  some  of  these  cases  the  destruction  or  the  formation  of  new  chemical  compounds 
by  oxidation,  deoxidation  or  other  reaction,  and  in  others  the  conditions  favorable  to 
life  are  removed  or  life  is  destroyed  by  high  temperature.  Of  the  first  class,  aerial  dis- 
infectants, those  most  employed  are  the  gaseous  sulphurous  anhydride,  the  fumes  of 
nitrous  acid,  with  chlorine  gas  and  vapors  of  bromine  and  iodine.  The  use  of  sulphurous 
anhydride,  obtained  by  burning  sulphur,  is  of  great  antiquity,  and  it  still  is  uuequaled 
as  a disinfectant  of  air,  on  account  both  of  its  convenience  and  its  general  efficacy. 
Camphor  and  some  volatile  oils  have  also  been  employed  as  air  disinfectants,  but  their 
virtues  lie  chiefly  in  masking,  not  destroying,  noxious  effluvia.  In  the  second  class, 
non-gaseous  disinfecting  compounds,  all  the  numerous  antiseptic  substances  may  be 
reckoned,  but  the  substances  principally  employed  in  practice  are  oxidizing  agents,  as 
potassic  manganates  and  permanganates. 

One  of  the  most  important  applications  of  antiseptics  has  been  their  introduction 
into  medical  and  surgical  practice.  Although  their  internal  administration,  with  the 
view  of  counteracting  diseases  believed  to  be  due  to  morbid  poisons,  has  not  hitherto 
yielded  any  marked  practical  result,  their  employment  in  the  treatment  of  wounds  has, 
in  the  bauds  of  Professor  Lister,  of  Edinburgh,  attracted  much  interest,  and  has  exer- 
cised an  important  influence  on  surgical  practice  during  the  past  ten  years.  Professor 
Lister,  adopting  the  germ  theory  of  putrefaction,  and  regarding  many  of  the  evils  arising 
in  connection  with  open  wounds  as  the  result  of  putrid  discharges,  produced  by  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  599 


agency  of  atmospheric  germs,  seeks  to  exclude  the  access  of  these  to  wounded  surfaces 
hy  the  employment  of  antiseptics,  particularly  carbolic  acid,  the  power  of  which  in 
destroying  living  organisms  is  undoubted.  Dressings  of  gauze  made  antiseptic  by  pre- 
vious treatment  with  strong  carbolic  acid,  are  applied  to  wounds.  The  acid  well  diluted 
with  water  is  likewise  employed  as  a lotion,  and  during  the  dressing  of  wounds  and  the 
performance  of  operations  is  also  applied  in  the  form  of  spray  to  the  surrounding 
atmosphere,  with  the  object  of  preventing  all  access  of  germs.  Boracic  acid  is  also 
employed  by  Mr.  Lister  as  an  antiseptic.  The  chief  benefits  claimed  for  the  method  of 
treatment  are,  that  wounds,  however  extensive,  may  heal  without  the  occurrence  of 
putrefaction  in  the  discharges,  and  that  thereby  the  risks  of  blood  poisoning  (pyaemia, 
etc.),  are  reduced  to  a minimum. 

Bichloride  of  mercury  (corrosive  sublimate)  has,  to  a certain  extent,  recently  super- 
seded carbolic  acid  in  surgical  and  sanitary  operations  ; but  the  relative  value  of  both 
agents  as  disinfectants,  antiseptics  and  germicides  must  be  still  further  investigated,  as 
we  shall  endeavor  to  demonstrate  by  the  method  of  experimentation  which  we  have 
indicated.  In  medical,  surgical  and  sanitary  practice  the  relative  poisonous  properties 
of  the  various  agents  employed  should  always  be  most  carefully  and  thoroughly  tested 
and  considered.  Thus  the  poisonous  properties  of  corrosive  sublimate  benefit  it  for  use 
in  many  sanitary  operations,  and  necessitate  the  utmost  precaution  in  its  use  in  medi- 
cine and  surgery.  We  cannot  separate  the  poisonous  properties  of  any  agent  from  its 
antiseptic  powers  when  the  foul  water  and  air  are  concerned,  and  when  human  life  may 
be  jeopardized  by  their  careless  or  ignorant  use  in  the  sick  room,  on  shipboard,  or  in 
hospital. 

Third  Series — Water. — Experiment  No.  6. — Ten  grains  of  well-formed,  healthy, 
rough  rice,  grown  by  Col.  Favrot,  in  the  neighborhood  of  Baton  Rouge,  Louisiana, 
loosely  enclosed  in  ordinary  clean  cotton  wool,  were  placed  in  the  upper  portion  of  a 
test  tube,  five  and  a half  inches  in  length  and  about  one-half  inch  in  diameter,  con- 
taining 350  grains  of  rain  water,  on  the  11th  of  May,  1886,  at  3 o’clock  p.m.  Tem- 
perature of  the  surrounding  atmosphere  in  my  practical  laboratory,  36  Dryades  street, 
84°  F.  On  the  14th  of  May  (fourth  day  of  the  experiment)  the  rice  had  commenced  to 
germinate,  each  grain  showing  signs  of  life,  sending  up  a delicate  white  sprout  through 
the  meshes  of  the  cotton  into  the  air,  and  below,  into  the  water,  a delicate  white  root. 
The  rice  continued  to  grow,  the  upper  sprouts,  or  stems,  presented  a delicate  greenish 
hue,  while  the  straight  white  roots  sent  out  numerous  delicate  white  rootlets  through 
the  water.  The  delicate  white  roots  passed  to  the  bottom  of  the  glass  test  tube,  attain- 
ing a length  of  five  inches,  and  the  stems  grew  to  a similar  height  above  the  layer  of 
cotton  in  the  upper  portion  of  the  tube. 

The  maximum  growth  was  attained  in  about  three  weeks,  and  the  green  color  of  the 
upper  sprouts  or  plants  gradually  faded,  and  on  the  14th  of  June  the  plants,  as  far  as 
the  upper  sprouts  or  plants  were  concerned,  presented  a withered  and  dried  appear- 
ance. On  examination,  I found  that  only  100  grains  of  water  remained  in  the  test 
tube;  250  grains  of  water  had  been  consumed  by  the  growing  rice  and  by  evaporation. 
The  loss  of  vitality  appeared  to  be  due  to  the  absence  of  the  necessary  saline  constitu- 
ents for  the  perfect  development  of  the  plants  after  the  transformation  of  the  organic 
elements  and  compounds  (starch,  sugar,  albumen  or  gluten)  into  cellular  elements,  and 
by  the  exhaustion  of  the  greatest  portion  of  water. 

Experiment  No.  7 — Repetition  of  Experiment  No.  6. — Ten  grains  of  rough  rice 
placed  in  cotton  wool  in  mouth  of  test  tube,  containing  350  grains  of  water,  at  the  same 
time  and  upon  the  same  day  (11th  of  May,  1886),  and  in  the  same  room.  The  grains 
sprouted,  and  followed  the  same  course  of  development  as  described  in  the  preceding 
experiment  (No.  6).  The  individual  plants  attained  the  same  size,  and  perished  about 
the  same  time.  At  the  expiration  of  both  experiments,  on  the  14th  of  June,  1886, 


600 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


although  the  upper  plauts  were  withered  and  apparently  dead,  the  roots  were  soft  and 
white,  and  the  remaining  parts  of  water  (100  grains  in  each  test  tube)  were  clear  and 
odorless,  and  the  plants  gave  forth  no  bad  odor. 

Fourth  Series — Corrosive  Sublimate  {Mercuric  Chloride , Bichloride  of  Mercury );  May 
11th,  1886;  temperature  of  the  atmosphere,  84°  F. — Ten  grains  of  rough  rice  were  loosely 
enclosed  in  cotton  wool  and  placed  in  the  mouth  of  a test  tube  of  similar  size  and  capacity 
as  that  used  iu  the  preceding  experiments.  Five  small  lots  of  rice  were  thus  prepared,  and 
assigned  to  five  test  tubes.  These  test  tubes  were  charged  with  solutions  of  corrosive 
sublimate  (mercuric  chloride),  one  grain  dissolved  in  100,  200,  400,  800  and  1600  grains 
of  water.  The  relative  properties  of  mercuric  chloride  to  the  water  is  illustrated  by 
the  following  fractions:  T-Jg-,  ^ J-j,  -gfa,  j^Vcr-  The  following  are  the  results  of  the 

individual  experiments: — 

Experiment  No.  8. — Ten  grains  of  rice  in  one  per  cent,  solution  of  bichloride  of 
mercury  (one  grain  in  100  grains  of  water).  No  germination  by  the  seeds  of  rice  at 
the  end  of  three  weeks. 

Experiment  No.  9. — Ten  grains  of  rice  immersed  in  solution  of  corrosive  sublimate, 
one  grain  dissolved  in  200  grains  of  water.  Grains  of  rice  remained  unchanged;  no 
germination  at  the  end  of  three  weeks. 

Experiment  No.  10. — Ten  grains  of  rice  immersed  in  solution  of  corrosive  sublimate, 
one  grain  dissolved  in  400  grains  of  water.  The  grains  of  rice  showed  no  signs  of  germi- 
nation at  the  end  of  three  weeks. 

Experiment  No.  11. — Ten  grains  of  rice  immersed  in  solution  of  corrosive  sublimate, 
one  grain  dissolved  in  800  grains  of  water.  Eight  grains  of  rice  showed  no  signs  of  ger- 
mination ; two  grains  in  the  second  week  of  the  experiment  showed  signs  of  feeble  ger- 
mination, and  fiually  attained  a height  of  one  and  three-quarter  inches  above  the  surface 
of  the  cotton  and  presented  a pale,  withered,  sickly  appearance  ; the  grains  also  sent 
small  roots  into  the  solution,  which  did  not  exceed  three-tenths  of  an  inch  in  length. 
These  two  grains  occupied  an  extreme  portion  of  the  upper  part  of  the  cotton.  The 
exact  date  of  the  commencement  of  germination  in  this  experiment  was  May  18th, 
and  all  signs  of  life  gradually  ceased  before  June  10th. 

Experiment  No.  12. — Ten  grains  of  rice  immersed  in  solution  of  one  grain  of  cor- 
rosive sublimate  in  1600  grains  of  water.  Four  grains  showed  no  signs  of  germination; 
six  grains  germinated,  sending  up  sickly,  pale  green  sprouts,  which  finally  attained, 
on  the  18th  of  May,  a length  of  from  one  to  one  and  three-quarter  inches,  and  then 
ceased  to  grow  and  gradually  withered.  The  whole  imperfectly  formed  roots  varied  in 
length  from  one-tenth  to  four  tenths  of  an  inch  in  length  and  did  not  penetrate  the 
water  to  any  depth.  The  products  of  the  germination  were  pale  and  stunted  in  the 
preceding  experiments  with  corrosive  sublimate. 

Numbers  8,  9,  10,  11  and  12  were  concluded  in  June,  1886.  The  weather  was  warm 
and  at  times  the  thermometer  stood  near  90°  F.  The  water  was  clear  in  the  five  test 
tubes,  and  free  from  odor  or  deposits;  the  grains  of  rice  presented  a clean,  undecomposed 
appearance.  They  were  firm  upon  pressure  and  had  not  undergone  putrefaction.  The 
loss  of  water  in  each  test  tube  was  about  100  grains,  about  250  grains  of  the  solution 
of  mercuric  chloride  remaining  iu  each  test  tube.  On  the  contrary,  the  experiments 
with  water  unadulterated,  250  grains  were  lost  and  only  100  grains  remained  in  the 
test  tube  ; it  would  appear,  therefore,  that  about  150  grains  of  water  were  consumed  or 
exhausted  by  the  growing  rice.  The  preceding  experiments  demonstrated  that  mer- 
curic chloride  is  both  germicidal  and  antiseptic.  On  the  18th  of  June  the  grains  of 
rice  employed  in  the  experiment  with  corrosive  sublimate  just  detailed  were  placed 
in  clear  water  and  allowed  to  remain  for  one  mouth.  During  this  period  there  were 
no  signs  of  germination. 

Fifth  Scries. — Carbolic  Acid. — New  Orleans,  May  11th,  1886;  temperature  of  atmos- 


AALAMAZOO  ACADEMY 
OF 

MEDICINE. 

SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  001 

phere  84°  F.  The  carbolic  acid  employed  in  these  experiments  was  the  crystallized 
Calvert  No.  1 ; regarded  as  the  purest  sample  of  carbolic  acid  offered  in  this  market. 
Ten  test  tabes  (with  ten  grains  of  rice)  enclosed  in  cotton  wool,  as  in  the  preceding 
experiments  with  corrosive  sublimate,  were  charged  with  solutions  of  carbolic  acid  of 
the  following  strengths  : one  grain  of  carbolic  acid  to  100  grains  of  water  ; one  grain 
to  200  grains  of  water  400,  800  and  1600  grains  of  water. 

Experiment  No.  13. — Ten  grains  of  rice  immersed  in  solution  of  one  grain  of  car- 
bolic acid  in  100  grains  of  water  ; up  to  the  18th  of  June  no  germination,  grains  of  rice 
sound,  no  putrefaction,  water  gave  a distinct  odor  of  carbolic  acid.  100  grains  of  water 
lost  out  of  the  original  350  grains.  When  transferred  to  pure  water  the  grains  did  not 
germinate. 

Experiment  No.  14. — Ten  grains  of  rice  immersed  in  solution  of  carbolic  acid,  one 
grain  in  200  grains  of  water.  Grains  did  not  germinate  up  to  end  of  experiment,  June 
18  ; at  the  latter  date,  water  clear  with  odor  of  carbolic  acid,  and  grains  of  rice  not 
decomposed,  but  presenting  a normal  appearance;  100  grains  of  water  lost  from  the  ori- 
ginal 350  grains  of  carbolic  solution  in  the  test  tube. 

Experiment  No.  15. — Ten  grains  of  rice  in  solution  of  one  grain  of  carbolic  acid  in 
300  grains  of  water. 

Experiment  No.  16.— Ten  grains  of  rice  in  solution  of  one  grain  of  carbolic  acid  in 
400  grains  of  water. 

Experiment  No.  17. — Ten  grains  of  rice  in  solution  of  one  grain  of  carbolic  acid  in 
800  grains  of  water. 

The  results  obtained  in  each  of  the  foregoing  experiments  (Nos.  15,  16,  17)  were 
similar  in  all  respects  with  those  of  experiment  No.  9,  namely,  no  germination  of  the 
rice,  no  putrefaction,  no  bad  odor  of  the  water,  and  the  loss  of  about  100  grains  of  water 
in  each  test  tube.  Experiments  closed  on  the  18th  of  June,  and  the  grains  transferred 
to  fresh  rain  water;  no  subsequent  signs  of  life  or  germination. 

Experiment  No.  18. — Ten  grains  of  rice,  immersed  in  solution  of  one  grain  of  car- 
bolic acid  in  1600  grains  of  water.  The  grains  of  rice  germinated  and  sent  up  a stem 
about  two  inches  in  height.  At  the  end  of  the  experiment  the  grains  of  rice  were 
black  and  soft  and  emitted  a putrid  odor;  the  water  was  turbid  and  emitted  a putrid 
odor.  It  is  clear,  from  these  experiments,  that  carbolic  acid  possesses  equal  if  not 
greater  germicidal  powers  than  corrosive  sublimate,  while  its  antiseptic  properties 
appear  to  be  less. 

Sixth  Series. — Red  Iodide  of  Mercury  ( Mercuric  Iodide ),  Biniodide  of  Mercury. — New 
Orleans,  June  20th,  1886.  Temperature  of  the  atmosphere,  88°  F. 

Experiment  No.  19. — Ten  grains  of  rice  enclosed  in  cotton  wool  and  immersed  in 
rain  water;  germination  of  each  grain  rapid,  and  the  results  similar  to  those  secured  in 
experiment  No.  6,  third  series. 

Nine  test  tubes,  of  similar  length,  diameter  and  capacity  with  those  employed  in 
the  preceding  experiments,  and  furnished  each  with  ten  grains  of  rice  on  the  necessary 
tufts  of  cotton  wool,  and  charged  with  the  following  solutions  of  the  red  iodide  of  mer- 
cury dissolved  in  water,  by  the  aid  of  the  iodide  of  potassium.  The  amount  of  iodide 
of  potassium  employed  was  just  sufficient  to  make  a perfectly  clear  solution  of  the  red 
iodide  of  mercury. 

Experiment  No.  20. — Ten  grains  of  rice  wrapped  in  cotton  wool  and  immersed 
in  solution  of  red  iodide  of  mercury  of  the  strength  of  ten  grains  dissolved  in  100 
grains  of  water  ; ten  per  cent,  solution.  No  germination  of  rice  on  the  23d  of  August, 
1886,  when  the  experiment  closed;  the  grains  of  rice  presented  a sound,  unaltered 
appearance,  with  no  marks  of  putrefaction,  although  the  thermometer  was  frequently 
near  100°  F. 

Experiment  No.  21. — Ten  grains  of  rice  immersed  in  solution  of  mercuric  iodide 


G02 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


of  the  strength  of  five  grains  in  100  grains  of  water.  No  germination  of  rice.  On 
23d  of  August,  rice  grains  unaltered  and  apparently  undecoinposed. 

Experiment  No.  22. — Ten  grains  of  rice  immersed  in  solution  of  mercuric  iodide 
of  the  strength  of  2.5  grains  in  100  grains  of  water.  The  result  was  the  same  as  in 
the  preceding  experiment — no  germination  ; on  the  23d  of  August  rice  grains  presented 
an  unaltered  appearance. 

Experiment  No.  23. — Ten  grains  of  rice  immersed  in  solut'on  of  mercuric  iodide 
of  the  strength  of  1.25  grain  to  100  grains  of  water.  Result  the  same  as  in  the  pre- 
ceding experiments — no  germination  ; on  the  23d  of  August  rice  grains  appeared  to  be 
unaltered  and  not  decomposed. 

Experiment  No.  24.  Ten  grains  of  rice  immersed  in  solution  of  0.5  grain  of 
mercuric  iodide  dissolved  in  100  grains  of  water  ; no  germination.  August  23d,  no 
change  to  the  naked  eye  in  the  grains  of  rice.  The  proportionate  strength  of  this  solu- 
tion was  one  grain  of  the  mercuric  iodide  dissolved  in  200  grains  of  water,  , 

Experiment  No.  25. — Ten  grains  of  rice  immersed  in  solution  of  0.25  grain  of  mer- 
curic iodide  in  100  grains  of  water;  the  strength  of  this  solution  was  one  grain  of 
mercuric  iodide  in  400  of  water  and  expressed  by  the  fraction  No  germination  ; 

on  the  23d  of  August  rice  had  not  sprouted  and  the  grains  appeared  to  be  unchanged 
and  without  marks  of  putrefaction. 

Experiment  No.  26. — Ten  grains  of  rice  immersed  in  a solution  of  mercuric  iodide 
of  the  strength  of  0.125  to  100  of  water  ; one  grain  of  mercuric  in  800  of  water, 

No  germination  ; on  the  23d  of  August  grains  of  rice  presented  an  unchanged  appear- 
ance. 

Experiment  No.  27. — Ten  grains  of  rice  immersed  in  shut  ion  of  mercuric  iodide, 
0.0625  in  100  grains  of  water;  relative  strength,  one  graiu  of  red  iodide  of  mercury  in 
1600  grains  of  water.  No  germination;  August  23d,  no  appearance  of  change  in  the 
rice  grains. 

Experiment  No.  28. — Ten  grains  of  rice  immersed  in  solution  of  mercuric  iodide, 
0.03175  grain  dissolved  in  100  grains  of  water.  Relative  strength,  one  grain  mercuric 
iodide  dissolved  in  3500  grains  of  water,  szoo-  Result  the  same  as  in  the  preceding 
experiments  ; no  germination,  and  no  putrefaction  of  the  rice  grains.  The  preceding 
experiments,  sixth  series  (experiments  19-28),  demonstrate  in  the  clearest  manner 
the  germicidal  and  antiseptic  properties  of  the  red  iodide  of  mercury,  which  appears  to 
possess  superior  powers  in  these  results  to  mercuric  chloride  (corrosive  sublimate). 

Seventh  Series — Blue  Vitriol  ( Sulphate  of  Copper , Cupric  Sulphate),  June  29th,  1886. — 
Temperature  of  the  atmosphere,  88°  P.  Six  test  tubes  provided  each  with  ten  grains  of 
rice  and  the  necessary  amount  of  cotton  wool,  and  the  following  solutions  of  cupric 
sulphate  were  used: — 

Experiment  No.  29. — Ten  grains  of  rice  immersed  in  solution  of  ten  grains  of  cupric 
sulphate  in  100  grains  of  water,  ten  per  cent,  solution.  No  germination  and  no  putre- 
faction up  to  close  of  experiment,  August  23d. 

Experiment  No.  30. — Ten  grains  of  rice  immersed  in  solution  of  five  grains  of  cupric 
sulphate  in  100  grains  of  water.  No  germination  aud  no  putrefaction  up  to  close  of 
experiment,  August  23d. 

Experiment  No.  31. — Ten  grains  of  rice  immersed  in  solution  of  2.5  grains  of 
cupric  sulphate  in  100  grains  of  water.  The  results  were  similar  to  those  of  29,30. 
No  germination  and  no  putrefaction. 

Experiment  No.  32. — Ten  grains  of  rice  immersed  in  solution  of  cupric  sulphate  in 
1.25  grains  in  100  grains  of  water.  No  germination  or  putrefaction  up  to  August  23d, 
1886. 

Experiment  No.  33. — Ten  grains  of  rice  immersed  in  solution  of  cupric  sulphate 
0.G25  in  100  grains  of  water.  No  germination  and  no  putrefaction. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  G03 


Experiment  No.  34. — Ten  grains  of  rice  immersed  in  solution  of  0.3125  grains  of 
cupric  sulphate.  No  germination  and  no  putrefaction. 

The  preceding  experiments  (series  7,  experiments  29,  30,  31,  32,  32,  34)  establish 
the  germicidal  and  antiseptic  properties  of  the  sulphate  of  copper,  even  in  small  pro- 
portions and  in  very  dilute  solutions. 

Eighth  Series — Green  Vitriol , ( Sulphate  of  Iron,  Ferric  Sulphate). — June  19th,  1886, 
temperature  of  the  atmosphere,  88°  F. 

Experiment  No.  35. — Ten  grains  of  rice,  immersed  in  solution  of  ten  grains  of  ferric 
sulphate  (green  vitriol)  dissolved  in  100  grains  of  water;  rice  did  not  sprout  or  putrefy. 

Experiment  No.  36. — Ten  grains  of  rice  immersed  in  solution  of  ferric  sulphate, 
five  grains  dissolved  in  100  grains  of  water;  rice  did  not  sprout  or  putrefy. 

Experiment  No.  37. — Ten  grains  of  rice  immersed  in  solution  of  ferric  sulphate,  2.5 
grains  in  100  grains  of  water. 

The  germination  of  the  rice  was  somewhat  retarded,  but  all  the  grains  sprouted, 
developed  vigorous  roots  and  leaves,  the  leaves  presented  a light  green  color  and 
attained  the  height  of  about  six  inches. 

Experiment  No.  38. — Ten  grains  of  rice  immersed  in  a solution  of  ferric  sulphate,  of 
the  strength  of  1.25  grains  dissolved  in  100  grains  of  water.  The  germination  was 
slightly  retarded,  but  the  rice  sprouted  and  grew  luxuriantly,  the  leaves  reaching 
about  eight  inches  in  length  and  of  a bright  green  color. 

From  the  preceding  experiments,  35,  36,  37  and  38,  it  is  evident  that  the  sulphate 
of  iron  (green  ferric  sulphate)  is  germicidal  and  antiseptic  only  in  strong  solutions, 
from  five  to  ten  per  cent.  In  weaker  solutions  the  ferric  sulphate  retards  but  does  not 
arrest  germination. 

Ninth  Series — The  Citrate  of  Iron , Quinia  and  Strychnia. — Compound  crystalline  salt, 
as  prepared  by  Powers  & Weiglitman,  was  employed  in  the  following  experiments: — 

Experiment  No.  39. — Ten  grains  of  rough  rice  immersed  in  a solution  of  ten  grains 
of  compound  salt,  citrate  of  iron,  strychnia  and  quinia,  dissolved  in  100  grains  of  water. 
Germination  retarded,  but  was  not  arrested,  and  the  plants  of  rice  finally  presented  a 
green  appearance. 

Experiment  No.  40. — Ten  grains  of  rice  immersed  in  a solution  of  five  grains  of  the 
citrate  of  iron,  strychnia  and  quinia;  germination  slightly  retarded,  but  not  arrested; 
growth  of  rice  vigorous. 

Experiment  No.  41. — Ten  grains  of  rice  immersed  in  solution  of  2.5  grains  of  the 
citrate  of  iron,  strychnia  and  quinia;  germination  prompt  and  vigorous;  blades  of  rice 
well  formed  and  of  a decided  green  color. 

In  the  preceding  experiments,  which,  like  those  with  the  ferric  sulphate,  were  per- 
formed simultaneously  and  in  the  same  room  and  atmosphere  with  those  of  the  corrosive 
sublimate,  carbolic  acid,  mercuric  iodide,  and  cupric  sulphate,  we  observe  that  the  com- 
pound salt  of  the  citrate  of  iron,  strychnia  and  quinia  did  not  arrest  the  germination 
of  the  seeds  of  rice. 

PRACTICAL  APPLICATIONS  AND  GENERAL  CONCLUSIONS  WITH  REFERENCE  TO  THE 

ANTISEPTIC  AND  GERMICIDAL  PROPERTIES  OF  SOME  OF  THE  AGENTS  STUDIED. 

First. — Substances  may  be  Germicidal  but  not  Antiseptic. — Thus,  hydrocyanic  acid  and 
cyanide  of  potassium  promptly  arrest  vegetable  and  animal  life,  but  do  not  arrest 
putrefaction. 

Second. — Mercuric  chloride  and  mercuric  iodide,  which  are  powerful  germicides  and 
antiseptics,  are  also  powerful  anti-syphilitic  remedies.  If  syphilis  be  due  to  a specific 
microorganism,  the  value  of  the  preparations  of  mercury  may  be  due,  in  part  at  least, 
to  their  power  to  destroy  syphilitic  germs  and  to  prevent  germination. 

The  author  has  employed  the  mercuric  chloride  and  mercuric  iodide  in  the  treat- 


604 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


ment  of  syphilis  during  the  past  thirty  years  with  successful  results,  and  has  found  the 
red  iodide  of  mercury  easily  administered  in  solution,  by  means  of  the  iodide  of  potas- 
sium, in  about  the  proportions  indicated.  We  have  employed  the  various  preparations 
of  mercury  as  blue  mass  (pil.  hydrargyri),  calomel  (mercurous  chloride),  corrosive  sub- 
limate (mercuric  chloride),  green  iodide  (mercurous  iodide),  red  iodide  (mercuric 
iodide),  black  oxide  (mercurous  oxide),  yellow  oxide  (mercuric  oxide),  in  the  treatment 
of  the  various  forms  of  syphilis  during  the  past  thirty  years,  and  have  been  led  to 
assign  the  first  place  to  the  red  iodide  of  mercury.  The  best  results  were  achieved  by 
the  use  of  the  following  formula: — 


R . Biniodide  of  mercury,  red  iodide  of  mercury gr.  iv 

Iodide  of  potassium.. ijiss 

Tincture  of  iodine f£  iij 

Peppermint  water fg  viiss.  M. 


One  teaspoonful  in  four  tablespoon  fuls  of  water,  three  times  a day. 

Each  dose  in  the  preceding  mixture  contains  about  one-sixteenth  of  a grain  of  the 
red  iodide  of  mercury,  held  in  solution  by  the  iodide  of  potassium;  the  strength  of  the 
solution  was  about  in  the  mixture,  and  less  than  when  diluted  for  internal 
administration.  In  the  preceding  prescription  the  red  iodide  of  mercury  is  held  in 
solution  by  the  iodide  of  potassium,  and  the  iodine  exists  in  the  free  state,  and  in  virtue 
of  its  physiological  and  therapeutical  properties  in  this  condition  excites  profound 
effects  upon  the  glandular  system.  Iodine  is  also  a potent  antiseptic,  disinfectant  aud 
germicide.  Such  a combination  as  that  just  given  is  not  merely  a powerful  alterative, 
but  is  also  an  effective  antiseptic  and  germicide.  I have  seen  a large  number  of 
patients  in  hospital  and  in  private  practice,  the  latter  greatly  outnumbering  the  former, 
relieved  of  the  most  threatening  and  distressing  symptoms  and  restored  to  good  health 
and  preserved  for  years  in  good  health,  by  the  use  of  the  above  combination  in  the 
treatment  of  constitutional  syphilis.  The  natural  tendency  of  the  syphilitic  poison  to 
induce  profound  anamiia  may  be  met  by  the  following  formula: — 

R . Red  iodide  (biniodide  of  mercury)  gr.  iv 

Iodide  of  potassium 3 j 

Tincture  of  iodine f,3  ij 

Syrup  of  iodide  of  iron f,3j 

Syrup  of  ginger .'. t'3  ivss 

Peppermint  water f(5  iij.  M. 

Dissolve  the  iodide  of  potassium  in  the  peppermint  water,  then  add  the  red 
iodide  of  mercury  and  tincture  of  iodine,  and,  finally,  the  syrups  of  the 
iodide  of  iron  and  ginger. 

Dose. — Teaspoonful  in  four  tablespoonfuls  of  water,  three  times  a day. 

We  have  the  same  dose  of  the  red  iodide  of  mercury  in  each  teaspoonful  of  both 
formula,  namely,  the  one-sixteenth  of  a grain. 

As  tested  in  over  five  hundred  cases  of  constitutional  syphilis,  the  effects  of  the  red 
iodide  of  mercury  held  in  solution  by  the  ipdide  of  potassium  are  to  reduce  glandular 
swellings,  heal  sore  places  on  the  head  and  limbs,  remove  syphilitic  eruptions,  alleviate 
or  cure  syphilitic  sore  throat,  remove  the  early  symptoms  of  paralysis,  promote  the 
decided  increase  of  the  red  globules  aud  restore  the  enfeebled  muscular  aud  nervous 
powers. 

We  must  attribute  the  great  value  of  the  red  iodide  of  mercury  in  the  treatment  of 
syphilis  not  merely  to  its  power  of  destroying  the  syphilitic  microorganisms,  hut  also  to 
its  power  as  a vigorous  germicide  or  alterative  to  the  glandular  enlargements  and  abnor- 
mal growths,  gummata,  tumors,  aud  mucous  and  cutaneous  eruptions,  tertiary  and 
osseous  degenerations,  characteristic  of  this  disease. 

The  power  of  the  red  iodide  to  arrest  germination  and  cell  proliferation  must  play 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  G05 

a most  important  part  in  its  arrest  and  eradication  of  the  action  of  the  syphilitic 
poison. 

In  like  manner  we  may  attribute  its  wonderful  powers,  when  locally  applied,  in  con- 
junction with  free  iodine,  to  goitres,  enlarged  glands  and  indolent  tumors,  to  its  power 
of  arresting  and  preventing  proliferation  of  the  cellular  elements.  I have  used  the 
red  iodide  of  mercury  in  combination  with  free  iodine  and  iodide  of  potassium  and 
the  extract  of  ergot,  with  beneficial  results,  in  the  treatment  of  cancers  of  the  womb 
and  mamnues,  before  the  appearance  of  ulceration,  and  also  in  fibrous  tumors  of  the 
uterus.  The  following  combination  appeared  to  arrest  the  growth  of  malignant  and 
non-malignant  tumors  in  some  cases  : — 


R.  Red  iodide  of  mercury gr.  ij 

Tincture  of  iodine f 3 ij 

Iodide  of  potassium .5j 

Syrup  of  the  iodide  of  iron f5j 

Squibb’s  fluid  extract  of  ergot f 5 iij 

Peppermint  water f 3 ij 


Dissolve  the  iodide  of  potassium,  red  iodide  and  tincture  of  iodine  in  the  pep- 
permint water,  and  then  add  the  syrup  of  the  iodide  of  iron  and  the 
fluid  extract  of  ergot. 

Dose. — 30  to  60  drops  in  teaspoonful  of  water,  three  times  a day. 

The  effect  of  the  ergot  upon  the  circulation  is  supplemented  by  the  germicidal 
powers  of  the  red  iodide  of  mercury  and  free  iodine.  The  syrup  of  the  iodide  of  iron 
tends  to  alleviate  the  profound  auremic  characteristics  of  the  cancerous  diathesis.  We 
have  been  led,  by  extended  experience,  to  regard  the  red  iodide  of  mercury  as  superior 
to  the  bichloride  of  mercury,  both  as  an  antiseptic  and  as  a germicide. 

Mercuric  Chloride:  Its  Value  as  an  Antiseptic  for  the  Destruction  of  the  Microorganisms 
of  Contagious  and  Infectious  Diseases. — Mercuric  chloride  is  not  merely  a violent  poison, 
destructive  alike  to  plants  and  animals,  but  it  also  clearly  belongs  to  the  class  antiseptics. 

Antiseptics  (anti,  against,  and  ag^roq,  putrid,  from  ogipig,  to  make  rotten),  substances 
which  have  the  property  of  preventing  or  arresting  putrefaction  in  dead  animal  or 
vegetable  matter. 

In  virtue  of  its  power  to  coagulate  albumen,  mercuric  chloride  may  be  regarded  as 
a corrosive  and  most  destructive  agent  to  all  forms  of  vegetable  and  animal  protoplasm, 
and  in  virtue  also  of  its  germicidal  power  may  be  regarded  as  a potent  disinfectant. 
Antiseptic,  disinfectant  and  germicidal  properties  are  not  necessarily  inseparable,  as 
may  be  shown  by  the  following  well-established  facts : Prussic  acid  and  cyanide  of 
potassium,  even  in  small  quantities,  destroy  animals  by  altering  the  composition  of  the 
blood  and  by  acting  upon  the  ganglionic  centres  of  the  sympathetic  and  cerebro-spinal 
systems,  and  more  especially  upon  the  ganglionic  centres  of  the  medulla  oblongata,  which 
preside  over  respiration,  and  upon  those  of  the  heart,  which  regulate  its  actions. 

But  hydrocyanic  acid  and  potassium  cyanide  possess  no  antiseptic  properties  ; rapid 
putrefaction  may  ensue  in  animals  destroyed  by  these  agents. 

Putrefaction  may  be  prevented  by  removing  one  or  more  of  the  conditions  essential 
to  its  occurrence.  Thus,  by  exclusion  of  the  atmosphere,  dead  matter,  which  would 
speedily  undergo  decomposition,  may  be  kept  intact  for  an  indefinite  length  of  time,  as 
shown  in  the  method  of  preserving  meat  by  hermetically  sealing  the  jars  after  the 
expulsion  of  the  air  by  heat.  Again,  the  preservative  influences  of  a low  temperature 
are  well  known,  and  extreme  cold  is  a powerful  antiseptic,  as  proved  in  the  case  of  the 
frozen  mammoth  of  northern  Asia.  Furthermore,  the  abstraction  of  moisture  will 
prevent  corruption  in  dead  matter. 

In  warm  and  dry  climates  animal  food  may  be  preserved  by  exposure  to  the  sun. 
In  the  ancient  practice  of  embalming  the  dead,  which  is  the  earliest  illustration  of  the 


606 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


systematic  use  of  antiseptics,  the  moister  portions  of  the  body  were  removed  before  the 
preservative  agents  were  added.  Numerous  chemical  substances  have  the  power  of 
counteracting  the  putrefactive  process.  Many  of  these  have  been  long  known  and  used 
for  this  purpose.  In  embalming,  besides  the  application  of  various  aromatics  and  resins, 
the  body  was  washed  with  cedar  oil  and  natron  (soda),  and  pitch  or  tar  were  used  as 
antiseptics.  Pitch  was  used  by  the  Romans  in  wine  making,  to  control  the  fermentative 
process.  The  fumes  of  sulphur  were  largely  employed  by  the  ancients  for  purposes  of 
purification,  while  common  salt  has  been  known  and  used  for  ages  as  one  of  the  best 
preservatives  from  decay.  The  mineral  acids  possess  antiseptic  properties,  as  do  also 
many  of  the  metallic  salts,  the  chloride  of  zinc,  in  the  form  of  Sir  W.  Burnett’s  disin- 
fecting fluid,  being  one  of  the  most  potent  of  them.  Alcohol  is  well  known  for  its 
power  of  preserving  animal  substances  from  decay.  Quinine  has  been  found  to  possess 
strong  antiseptic  properties.  The  tar  products,  notably  carbolic  acid,  are  among  the 
most  approved  and  extensively  used  of  all  antiseptic  agents. 

The  various  substances  named  possess  the  power  of  preventing  putrefaction  in  dead 
animal  or  vegetable  matter,  and  to  a greater  or  less  degree  of  arresting  it  when  already 
begun.  They  likewise  exert  a similar  action  on  the  analogous  process  of  fermentation. 
They  differ  from  mere  disinfectants  which  destroy  the  emanations  from  putrescent 
material,  but  do  not  necessarily  arrest  the  progress  of  decay.  Some  antiseptics,  how- 
ever, such  as  sulphurous  acid,  are  powerful  disinfectants  also,  while  others,  such  as 
quinine,  have  no  disinfectant  properties  at  all.  Mercuric  chloride  not  merely  coagu- 
lates the  albumen  of  living  germs,  and  in  all  organic  fluids  and  solids  containing  this 
substance,  but  is  in  itself,  in  virtue  of  its  inherent  properties,  a most  potent  poison  to 
man  and  animals,  whether  administered  internally  or  applied  externally.  Corrosive 
sublimate  induces  in  man  symptoms  of  the  most  violent  character,  which  cannot  wholly 
be  explained  by  its  power  of  coagulating  albumen.  In  the  present  state  of  knowledge 
we  cannot  give  a rational  explanation  of  the  fact  that  a few  grains  of  corrosive  subli- 
mate, or  of  arsenious  acid,  or  of  strychnine,  are  capable  of  destroying  the  most  powerful 
human  being.  On  the  contrary,  why  are  many  mineral  substances  which  have  no 
established  relations,  chemical  or  physical,  to  the  human  system  completely  inert?  It 
is  evident  that  corrosive  sublimate,  even  in  minute  quantities,  is,  independently  alto- 
gether of  its  chemical  and  physical  properties,  a direct  and  most  potent  poison  to  all 
the  various  forms  of  animal  and  vegetable  life.  The  poisonous  properties  of  this  agent 
must,  therefore,  be  considered  in  its  use  as  an  internal  remedy  and  as  an  antiseptic  and 
disinfectant.  In  its  use  in  hygienic  and  sanitary  operations  the  following  facts  should 
be  carefully  considered  : — 

1.  When  mercuric  chloride  is  used  in  solution  for  the  disinfection  of  clothing,  fur- 
niture and  floors,  in  private  houses,  hospitals  or  ships,  the  potency  of  the  solution  used 
will  decrease  in  a ratio  corresponding  with  the  amount  of  animal  and  vegetable  albumen 
present.  Of  course,  the  coagulation  and  chemical  alteration  of  albuminoid  substances 
is  a powerful  means  of  destroying  the  germicidal  powers  and  arresting  the  life  acts  of 
pathogenic  organisms,  and  of  altering  and  arresting  the  process  of  septic  fermentation 
or  putrefaction.  But  that  portion  of  the  disinfectant  which  accomplishes  these  changes 
must  be  regarded  as  having  accomplished  a detiuite  result,  and,  therefore,  as  being 
withdrawn  from  the  further  process.  In  other  words,  sanitary  officers  should  bear 
these  facts  continuously  in  mind,  and  use  in  their  operations  large  and  efficient  quan- 
tities of  the  bichloride.  In  the  practical  operations  of  disinfecting  clothing,  houses  and 
ships,  the  solution  of  bichloride  should  be  more  concentrated  than  those  usually  recom- 
mended by  writers  who  base  their  view  upon  the  experiments  of  Koch,  Miquel,  Croix 
and  others.  In  sanitary  operations  it  must  also  be  considered  that  the  influence  of 
certain  substances  and  conditions  on  microorganisms  may  be  twofold — 

(a)  The  condition  may  be  unfavorable  to  the  growth  of  the  organism. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  G07 


(b)  The  condition  may  be  fatal  to  the  existence  of  the  microorganism. 

2.  In  the  disinfection  of  drains,  yards  and  privies  by  corrosive  sublimate,  it 
must  he  borne  in  mind  (a)  that  the  salt  is  immediately  decomposed  by  lime,  ammonia 
and  all  alkalies;  (5)  when  not  thus  decomposed,  the  poisonous  mercuric  chloride  may  find 
its  way  into  wells  and  springs,  and  thus  induce  poisonous  effects  upon  human  beings. 
The  ordinary  strength  of  the  solution  of  corrosive  sublimate  recommended  by  sanitarians 
for  disinfection,  one  part  to  1000  of  water,  is  entirely  inadequate  to  the  proper  and 
thorough  disinfection  of  foul  privies  and  to  the  foul  bilge  water  and  ballast  of  infected 
ships. 

If  the  ballast  of  a ship  be  composed  of  carbonate  of  lime,  the  bichloride  will  neces- 
sarily suffer  chemical  change.  In  foul  privies,  sulphuret  of  ammonia  and  carbonate 
of  ammonia  are  present  in  large  quantities,  and  large  quantities  of  the  bichloride  will 
he  decomposed,  the  sulphuret  of  the  peroxide  of  mercury,  which  possesses  little  or  no 
germicidal  properties,  being  formed. 

3.  The  careless  use  of  such  a deadly  poison  as  mercuric  chloride  in  sanitary  and 
quarantine  operations  may  indirectly  or  directly  lead  to  fatal  accidents,  and  will  afford 
an  easy  opportunity  for  the  commission  of  murder  by  poisoning.  Since  the  establish- 
ment of  the  preparations  of  arsenic  for  the  destruction  of  the  cotton  worm  and  other 
vermin,  about  twenty  cases  of  arsenical  poisoning  of  planters  and  their  families  by 
negro  servants  and  laborers,  as  well  as  a large  number  of  mules,  horses  and  cattle,  have 
come  under  my  observation  and  been  subject  to  my  examination.  This  country  has 
suffered  much  from  the  unrestrained  and  uncontrolled  use  of  poisons. 

4.  When  a solution  of  mercuric  chloride  comes  in  contact  with  metal  it  is  decom- 
posed, metallic  mercury  being  deposited.  Thus,  when  iron,  copper  or  brass  pumps  are 
used  in  the  disinfection  of  ships,  by  means  of  weak  solutions  of  the  bichloride  of  mer- 
cury, a certain  portion  of  the  salt  is  decomposed,  to  the  injury  of  the  apparatus.  And 
when  the  solution  of  free  mercury  is  squirted  over  the  walls  of  the  cabins  and  vaults, 
all  gilded  surfaces,  all  articles  of  jewelry,  watches,  etc.,  metallic  buttons  on  male  or 
female  attire,  alter  in  like  manner  and  receive  a film  of  metallic  mercury. 

5.  The  bichloride  of  mercury  is  volatilized  by  heat,  but  it  is  erroneous  to  suppose 
that  any  large  area  can  be  pervaded  by  its  fumes,  unless  the  closed  chamber  or  oven 
containing  the  clothing  to  be  disinfected  is  elevated  to  a degree  of  heat  destructive  of 
the  textile  fabrics. 

6.  When  the  attempt  is  made  to  charge  steam  with  the  bichloride  of  mercury  by 
boiling  the  solution,  the  salt  will  remain  in  the  boiler  and  will  not,  to  any  extent, 
escape  with  the  steam. 

7.  The  solution  of  the  bichloride  of  mercury  is  unfitted  for  the  disinfection  of  car- 
goes of  coffee,  or  of  grain  or  any  kind  of  food,  in  that  it  imparts  poisonous  properties  to 
all  articles  of  food  with  which  it  comes  in  contact. 

CARBOLIC  acid:  ITS  VALUE  AS  AH  ANTISEPTIC  AND  GERMICIDE;  COMPARISON 

WITH  MERCURIC  CHLORIDE. 

The  experiments  which  are  here  detailed,  illustrating  the  influence  of  certain  agents 
upon  the  germination  and  growth  of  rice,  have  shown  that  carbolic  acid  possesses  ger- 
micidal powers  similar  to  those  of  mercuric  chloride.  These  results  are  at  variance 
with  those  obtained  by  Koch,  Miquel,  Davaine  and  other  experimenters,  and  it  is  evi- 
dent that  we  must  exercise  great  care  in  arriving  at  any  settled  conclusions  from  experi- 
ments made  upon  one  organism  with  reference  to  the  amount  which  may  be  necessary 
to  prevent  the  development  of  another. 

The  method  of  experimentation,  also,  as  well  as  the  time  consumed  in  the  perform- 
ance of  the  experiments,  and  the  vital  endowments  of  the  organisms  experimented  on, 
must  be  carefully  considered.  With  reference  to  the  experiments  with  carbolic  acid. 


608 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


we  observe  that  Koch  found  a one  per  cent,  solution  to  he  without  effect  in  anthrax 
spores  after  fifteen  days’ exposure;  a two  per  cent,  solution  retarded  the  development 
of  spores,  hut  did  not  completely  destroy  their  vitality,  in  seven  days;  a three  per  cent, 
solution  was  effective  in  three  days;  in  the  absence  of  spores,  a one  per  cent,  solution 
quickly  destroys  the  vitality  of  anthrax  bacilli.  Koch  recommends  a five  per  cent, 
solution  in  the  destruction  of  the  comma  bacillis  of  Asiatic  cholera,  and  a two  per  cent, 
solution  for  the  disinfection  of  surfaces  and  articles  soiled  by  such  discharges. 

While  acting  as  President  of  the  Board  of  Health  of  the  State  of  Louisiana,  1880- 
1884,  the  author  employed  carbolic  acid  effectively  as  a disinfectant,  in  strength  varying 
from  two  to  ten  per  cent.  Dr.  Sternberg  has  found  that  in  the  proportion  of  one  to  two 
hundred,  these  agents  destroy  bacterium  termo,  a septic  micrococcus  (M.  Pasteur)  in 
active  growth,  while  one  to  twenty-five  failed  to  destroy  the  bacteria  in  putrid  beef  tea. 
A micrococcus  obtained  from  the  pus  of  an  acute  abscess  was  destroyed  by  0.8  per  cent., 
while  five  per  cent,  failed.  In  all  of  these  experiments  by  Dr.  Sternberg,  the  time  of 
exposure  was  two  hours — a time  far  too  short  to  afford  results  applicable  to  practical 
sanitary  operations.  According  to  Simon,  the  micrococcus  of  swine  plague  multiplies 
abundantly  in  urine  containing  one  per  cent,  of  carbolic  acid;  while  the  micrococcus  of 
fowl  cholera  is  destroyed  by  six  hours’  exposure  in  a solution  of  this  strength  (one  per 
cent.),  and  two  per  cent,  destroys  the  bacterium  of  symptomatic  anthrax  (dried  virus) 
in  forty-eight  hours.  According  to  the  researches  of  Antoin,  Cornevin  and  Thomas, 
Davaine  showed  by  inoculation  experiments  that  anthrax  bacilli  in  fresh  blood  are 
destroyed  by  being  exposed  to  the  action  of  a one  per  cent,  solution  for  one  hour. 

Schill  and  Fischer  found  that  the  infecting  power  of  tuberculous  sputum,  as  shown 
by  inoculation  into  Guinea  pigs,  is  destroyed  by  twenty-four  hours’  exposure  to  a twenty- 
five  per  cent,  solution  of  carbolic  acid.  The  same  result  was  obtained  with  a three  per 
cent,  solution,  while  one  and  two  per  cent,  solutions  tailed. 

The  experiments  which  the  author  has  detailed  with  rice  assign  more  strongly  anti- 
septic and  germicidal  powers  to  carbolic  acid  than  those  just  quoted,  while,  on  the  other 
hand,  they  indicate  that  the  mercuric  chloride  is  much  less  potent  than  would  appear 
from  the  following  statements. 

Many  experimenters  regard  corrosive  sublimate  as  the  most  powerful  antiseptic, 
since  even  solutions  as  weak  as  1 to  300,000  are  said  to  inhibit  the  growth  of  bacillus 
anthracis.  According  to  Koch,  mercuric  chloride,  in  the  proportion  of  1 to  1000, .destroys 
all  spores  in  a few  minutes,  and  that  the  vitality  of  anthrax  spores  is  destroyed  by 
much  weaker  solutions  (1  to  10,000)  when  the  time  of  exposure  is  prolonged.  The 
experiments  of  Sternberg,  repeating  those  of  Koch  and  other  observers,  have  given 
similar  results. 

NECESSITY  FOR  MORE  CAREFUL  AND  SIMPLER  EXPERIMENTS  TO  DETERMINE  THE 
ACTUAL  VALUE  OF  DIFFERENT  ANTISEPTICS  IN  THE  DESTRUCTION  OF 
PATHOGENIC  ORGANISMS. 

In  dealing  with  the  causes  and  prevention  of  such  fearful  scourges  as  yellow  fever 
and  Asiatic  cholera,  those  charged  with  the  sanitary  operations  necessary  to  an  effectual 
system  of  Public  and  International  Hygiene  need  exact  data  with  reference  to  the 
relative  value  and  most  effective  methods  of  employing  antiseptics  and  disinfectants. 
Professor  E.  Klein,  M.D.,  f.r.s.,  has  placed  in  a clear  light  the  imperfection  of  the 
knowledge  of  sanitarians  with  reference  to  the  actual  power  of  such  antiseptics  as  car- 
bolic acid  and  mercuric  chloride  to  destroy  the  microorganisms  which  are  regarded  as 
intimately  associated  with  certain  diseases  and  diseased  processes.  This  acute  observer 
says:  “By  sowing  any  microorganisms  into  a nourishing  solution  to  which  has  been 
added  a certain  substance,  as  carbolic  acid,  to  the  amount  of  one  per  cent.,  and  exposing 
this  medium  to  the  conditions  of  temperature  and  moisture  otherwise  favorable  to  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  609 


growth  of  the  organism,  it  is  found  that,  after  the  lapse  of  a due  period,  the  growth  is 
retarded  or  altogether  inhibited;  the  conclusion  is  reached  that  this  substance — namely, 
carbolic  acid  of  one  per  cent. — is  an  antiseptic.” 

There  is  nothing  more  fallacious  than  this  mode  of  reasoning;  a great  many  micro- 
organisms can  be  exposed  to  a one  per  cent,  solution  of  carbolic  acid  for  hours  without 
in  the  least  being  affected ; for  on  being  then  transferred  to  a suitable  nourishing  medium, 
they  grow  and  thrive  well.  Similarly,  by  placing  the  spores  of  bacillus  authracis  in  a 
proteid  medium  containing  perchloride  of  mercury  of  the  strength  of  1 to  300,000,  it 
is  found  (as  Koch  has  shown)  that  the  spores  are  absolutely  incapable  of  germinating. 
But  from  this  the  conclusion  is  drawn  that  perchloride  of  mercury  of  the  strength  of 
1 to  300,000  is  a germicide.  Dr.  Klein  most  strongly  dissents;  for  perchloride  of  mer- 
cury, even  of  the  strength  of  one  per  cent.,  is  not  a germicide  any  more  than  vinegar; 
for  on  placing  the  spores  of  bacillus  anthracis  in  a proteid  medium  to  which  so  much 
vinegar,  or  any  other  acid,  has  beeu  added  as  makes  it  decidedly  acid,  it  will  be  found 
that  the  spores  do  not  germinate.  In  order  to  pronounce  a certain  substance  an  anti- 
septic, in  the  strict  sense  of  the  word,  it  is  necessary  to  place  the  organisms  in  this  sub- 
stance for  a definite  time,  then  to  remove  them  thence,  and  to  place  them  in  a suitable 
nourishing  medium.  If  they  then  refuse  to  grow,  the  conclusion  is  justified  that  the 
exposure  has  injured  or  destroyed  the  life  of  the  organism.  In  the  case  of  pathogenic 
organisms,  a substauce,  to  be  pronounced  a germicide,  must  be  shown  to  have  this 
power,  that  when  the  organism  is  exposed  to  the  substance,  and  then  introduced  into 
a suitable  artificial  medium,  it  refuses  to  grow;  and  it  must  also  be  shown  that  when 
introduced  into  a suitable  animal,  it  is  incapable  of  producing  the  disease  which  the 
same  organism,  unexposed  to  the  substance  in  question,  does  produce. 

Dr.  E.  Klein  has  made  many  observations  on  microorganisms,  both  putrefactive  and 
pathogenic,  and  has  found  that  many  assertions  hitherto  made  on  this  subject,  treated 
in  the  above  light,  are  absolutely  untrustworthy  and  erroneous.  According  to  this 
observer,  various  species  of  putrefactive  micrococci,  bacterium  termo,  bacillus  subtilis, 
various  pathogenic  microorganisms,  as  bacillus  anthracis,  bacillus  of  swine  fever,  abso- 
lutely refuse  to  grow  in  media  to  which  is  added  plienyl-proprionic  acid,  or  phenyl- 
acetic  acid,  to  an  amount  so  small  as  one  in  1600;  but  if  the  same  organisms  are  exposed 
to  these  substances  in  much  stronger  solutions— 1 to  800,  1 in  400,  or  even  one  in  200 — 
and  then  transferred  to  a suitable  nourishing  material,  it  is  found  that  they  have 
completely  retained  their  vitality  : they  multiply  as  if  nothing  had  been  done  to 
them. 

Dr.  Klein  has  exposed  the  spores  of  bacillus  anthracis  to  the  above  acids,  of  the 
strength  of  1 in  200,  for  forty-eight  hours  and  longer,  and  then  inoculated  guinea  pigs 
with  them,  and  found  that  the  animals  died  of  typical  anthrax  in  exactly  the  same 
way  as  if  they  had  been  inoculated  with  pure  spores  of  the  bacillus  anthracis.  Koch 
has  published  a large  series  of  systematic  observations  made  in  testing  the  influence  on 
spores  of  bacillus  anthracis  of  a large  number  of  antiseptics  (thymol,  arsenite  of  potas- 
sium-, turpentine,  clove  oil,  iodine,  hydrochloric  acid,  permanganate  of  potassium, 
eucalyptol,  camphor,  quinine,  salicylic  acid,  benzoic  acid  and  many  others),  and  among 
them  he  found  perchloride  of  mercury  to  be  the  most  powerful,  since  even  a solution 
of  1 in  600,000  is  capable  of  impeding,  one  of  1 in  300,000  of  completely  checking,  the 
germinating  power  of  the  spores. 

Klein  has  shown  that  to  legard  these  substances,  from  these  observations  of  Koch, 
in  any  way  as  antiseptics  for  the  spores  of  bacillus  anthracis,  would  be  no  more  justifi- 
able than  to  consider  a weak  vinegar  as  such.  Perchloride  of  mercury,  a solution  of  1 in 
300,000,  is  no  more  capable  of  interfering  with  the  life  and  functions  of  the  spores  of 
bacillus  anthracis  than  water  or  salt  solution;  for  the  spores  maybe  steeped  in  this 
solution  for  any  length  of  time,  and  yet,  on  being  transferred  to  any  suitable  medium 
Vol.  IV— 39 


610 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


they  grow  and  multiply  rapidly,  and  when  inoculated  into  rodents  they  produce  fatal 
anthrax  with  absolute  certainty. 

In  common  with  Dr.  Blythe,  Medical  Officer  of  Health  for  the  Marylebone  District, 
in  London,  Dr.  Klein  tried  the  action  of  a number  of  substances  in  common  use  as 
antiseptics,  namely,  Calvert’s  fluid,  pure  terebene.  phenol  ten  per  cent.,  perchloride  of 
mercury  one  per  cent.,  on  the  spores  of  bacillus  anthracis,  exposing  them  in  compara- 
tively large  quantities  of  the  above  fluid  (the  two  being  well  mixed)  for  twenty-four 
hours,  and  then  inoculating  Guinea  pigs  with  them  (spores  and  antiseptics).  The  ani- 
mals died  with  symptoms  of  typical  anthrax,  the  blood  teeming  with  the  bacillus 
anthrax.  These  substances,  then,  are  no  more  antiseptics,  and  still  less  germicides,  for 
the  spores  of  the  bacillus  anthracis  than  water  is. 

In  all  these  inquiries,  particularly  in  those  upon  pathogenic  organisms  capable  of 
forming  spores,  the  influence  of  the  substances  must  be  judged,  not  merely  by  their 
action  on  the  organisms,  but  also  on  the  spores,  as  in  this  very  case  of  the  bacillus 
anthracis.  The  bacilli  taken  from  the  blood  of  an  animal  dead  of  authrax  are  killed 
after  an  exposure,  of  say  ten  minutes,  to  a solution  of  phenyl-propionic  acid  the  strength 
of  1 in  400,  or  even  1 in  800,  whereas  the  spores  of  the  bacilli  (produced  in  artificial 
cultures)  withstand  complete  exposure  to  this  acid  of  any  strength,  and  for  any  length 
of  time.  Bacteria  belong  to  the  vegetable  kingdom.  Ammonia  dissolves  the  eggs, 
the  embryos  of  all  animals,  the  bodies  of  all  the  inferior  infusoria,  attacks  the  sperma- 
tozoa, etc.,  while  it  leaves  absolutely  intact  all  the  varieties  of  cellulose  and  the  repro- 
ductive elements  of  plants,  whether  it  is  used  cold  or  boiling.  Concentrated  acetic  acid 
causes  all  animal  tissues  to  become  pale,  while  it  is  without  action  on  bacteria;  hsematoxy- 
lou  and  fuclisin  color  bacteria  deeply.  We  should,  therefore,  no  longer  give  to  the  bac- 
teria the  names  of  microscopic  animalculse,  infusoria,  microzoa  and  other  names  which 
imply  animal  origin,  nature  and  functions. 

In  conclusion,  the  author  expresses  the  hope  that  the  method  of  experimental 
research  which  he  has  endeavored  to  illustrate  may  be  employed  in  the  determination 
of  the  antiseptic  and  germicidal  powers  of  many  substances  now  employed  in  the  prac- 
tical operations  and  applications  of  medical  and  sanitary  science. 


NOTES  SUR  LE  DANGER  DES  CONSERVES  ALIMENTAIRES  POUR 

LA  SANTE  PUBLIQUE. 

ON  THE  DANGER  OF  CANNED  GOODS  TO  THE  PUBLIC  HEALTH. 

BEMERKUNGEN  UBER  DIE  GEFAHRLICHKEIT  CONSERVIRTER  NAHRUNGSMITTEL  FUR 

DIE  OFFENTLICIIE  GESUNDHEIT. 

PAR  LE  DR.  LADMIRAULT. 

Louisiana. 

Depuis  plusieursannees  les  journaux  de  Medecine  des  Etats  Unis  rapportent  des  cas 
d’empoisonnement  par  l’usage  de  conserves  alimentaires.*  Une  Cour  de  Justice  de  New 
York  l’annee  deruiere  avait  it  juger  une  plainte  en  dommages  pour  empoisonnement 
d’une  famille  par  des  tomates  en  boites,  preparees  par  un  fermier.  Un  jeune  horarae  de 
quatorze  ans  raconta  comment  il  formait  le  trans  inutile  fait  aux  caverales  des  boites. 
II  usait  de  veritable  chlorure  de  zinc  qui  p6netrait  un  quantity  dans  les  boites  souveut 
avec  de  la  soude  compos6e  de  deux  parties  de  plomb  et  une  detain  ainsi  que  les  ou- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  611 


vriers  qui  usent  de  cette  composition  pour  souder  de  preference  it  la  r6sine  il  mettait 
dans  l’acide  chlorhydrique  des  fragments  de  feuillesde  zinc  jusqu’ii  ce  que  toute  ebulli- 
tion ait  cesse,  e’est  ce  que  les  ouvriers  ferblantiers  appellent  eteiudre  l’acide.  En  pas- 
sant avec  mes  pinceaux  ce  liquide  sur  le  for  blauc,  il  s’eckaulle  et  la  soudure  qu’ou  y 
applique  avec  le  fer  a souder  adhere  promptemeut,  mais  la  trace  de  poin^ou  laisse  passer 
ce  cblorure  et  meme  la  soudure.  Les  substances  coutenues  dans  les  boites  en  sont  tene- 
ment impregn6es  qu’elles  sout  decolorees.  Que  foil  ouvre  une  boite  de  salmon,  mac- 
kerel, canned  beef,  lunch  tongues  d’  Armour  and  Plankington,  on  les  trouvera  decolo- 
rees  et  recouvertes  sonvent  d’une  couche  noire  qui  n’est  autre  chose  qu’un  sulfure 
detain  de  plomb  ou  de  ziuc.  Derniorement  j’ai  vu  un  empoisonuement  par  une  eau  de 
salmon.  Une  famille  en  avait  soupe.  Une  demi-heure  aprfes  le  repas.  ceux  qui  en 
avaient  mange  furent  pris  de  coliques,  vomissement  et  diarrhee  avec  prostration  ex- 
tremes. Ces  accidents  se  calmerent  au  bout  de  trois  jours,  sauf  un  des  enfants  chez 
qui  ils  persistferent  jusqu’au  cinquifeme  jour. 

Je  fus  alors  appele,  et  quelques  calmants  amenerent  un  prompt  retablissenient.  Les 
personnes  de  la  famille  qui  n’avaient  pas  mange  de  ce  salmon  ne  furent  pas  malades. 

Les  conserves  preparees  par  ce  precede  sont  done  dangereuses  pour  la  sante  publique. 
Tel  n’est  pas  celui  d’Appert  qui  en  est  l’inventeur.  Il  consiste  tout  simplement  il  ren- 
fermer  la  substance  ii  conserver,  qu’elle  soit  cuite  ou  crue,  dans  un  vase  kermetiquement 
ferine,  it  soumettre  le  vase  et  son  contenu  il  la  chaleur  du  bain  marie  ou  mieux  de  la 
vapeur.  La  perforation  des  couvercles,  dans  le  but  illusoire  de  chasser  l’air  n’est  pas 
necessaire,  cause  un  surcroit  de  depenses,  perte  de  temps,  etintroduit  dans  ces  aliments 
des  substances  veneneuses. 

Appert  pour  contenir  ses  conserves  se  servait  de  vases  de  verre  ce  qui  lui  causait  beau- 
coup  de  traces  pour  un  bouchage  hermetique,  et  toujours  un  peu  de  casse  des  bouteil- 
les.  L’industrie  lui  substitua  avec  succes  des  boites  de  fer  blanc,  et  devint  universelle. 

Main  tenant  quel  est  l’agent  couservatif?  Telle  etait  la  question  adressee  il  l’inven- 
teur par  les  membres  du  Comite  Consultatif  des  arts  et  metiers  devant  qui  il  faisait  ses 
experiences.  Il  repoudait  e’est  la  chaleur  qui  ddtruit  les  germes  de  putrefaction,  idee  par- 
faitement  conforme  aux  decouvertes  ulterieures  des  germes  des  diflerentes  especes  de 
fermentation.  La  chimie  et  le  microscope  en  demontrent  1’ existence.  Apres  ces  expe- 
riences d’Appert,  et  l’epreuve  de  leurs  produits  en  parfaite  conservation,  apres  un 
temps  assez  long,  et  les  recompenses  du  Gouvernement  Francjais,  il  exposa  dans  un 
pamphlet  intitule  le  livre  de  tous  les  menages,  tout  le  detail  de  ses  precedes,  qui  ne 
compromettaient  nullement  la  sante  publique.  Dans  ce  livre  il  indique  avec  precision 
le  temps  necessaire  d’exposition  il  la  chaleur  du  bain  marie  ou  de  la  vapeur  pour  la  con- 
servation du  nombre  des  substances  alimentaires. 

Les  boards  of  health  des  differents  Etats  devraient  done  interdire  la  vaste  de  tout 
lan  qui  a ete  poncture  et  resoude,  et  publier  une  instruction  sur  les  simples  operations 
necessaires  pour  cette  fabrication. 


612 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


A NEW  METHOD  FOR  THE  CERTAIN  DETECTION  OF  THE 
TRICHINA  SPIRALIS  IN  MEAT. 

UNE  METIIODE  NOUVELLE  POUR  DECOUVRIR  LA  TRICHINE  SPIRALE  DANS 

LA  YIANDE. 

UBER  EINE  NEUE  METHODE  ZUR  SICHEREN  ENTDECKUNG  DER  TRICHINA  SPIRALIS  IM 

FLEISCHE. 

BY  JAMES  A.  CLOSE,  M.  D. , M.  B. , L.  R.  C.  S.,  EDIN.,  ETC., 

Of  Summerfield,  III. 

I have  the  honor  of  presenting  to  you,  this  morning,  a new  method  for  detecting  the 
trichina  spiralis  in  meat,  whether  encysted  or  free. 

As  far  as  my  reading  and  observation  extend,  the  only  methods  hitherto  employed 
have  been — 

1.  The  teasing  or  tearing  of  the  suspected  muscle  under  a dissecting  microscope,  or 

2.  The  method  of  placing  thin  pieces  of  the  meat  between  two  glass  slides,  and 
applying  pressure,  when,  if  the  worms  are  encysted,  they  can  be  easily  seen  under  a 
low  power  of  the  microscope. 

The  first  of  the  above-mentioned  methods  is  often  excessively  tedious,  and  in  case 
the  meat  contains  but  few  worms,  say  four  or  five  to  the  cubic  inch,  a prolonged  exami- 
nation by  this  method  might  give  only  negative  results. 

The  second  method  gives  very  good  results  when  the  worms  are  encysted,  as,  by 
using  quite  thin  pieces  of  the  meat,  and  applying  moderate  pressure,  the  cysts  can  be 
readily  seen.  But,  if  the  examiuation  were  made  within  forty  to  sixty  days  after  the 
animal  from  which  the  meat  was  taken  was  infected,  the  worms  would  not  be  encysted, 
and  the  examiner  would  be  compelled  to  rely  upon  the  detection  of  a free  worm. 

The  chief  objections  that  can  be  urged  against  the  above-mentioned  methods  are: — 

1.  The  non-discovery  of  trichinae  in  a specimen  of  meat,  by  those  methods,  is  not 
proof  positive  that  none  exist  in  it. 

2.  Both  methods  require  that  the  examiner  possess  at  least  a moderate  amount  of 
skill. 

By  the  method  which  I propose  to  demonstrate  this  morning,  it  would  be  perfectly 
feasible  to  detect  the  presence  of  the  worms,  even  if  the  meat  contained  but  one  worm 
to  a cubic  inch.  The  examination  requires  also  but  a minimum  amount  of  skilled 
labor,  as  most,  if  not  all,  of  the  work  can  be  performed  by  an  office  boy  or  household 
servant  of  ordinary  intelligence. 

The  method  is  as  follows:  The  meat  to  be  examined  is  freed,  as  far  as  possible, 
from  fat,  and  minced  somewhat  finely,  and,  if  salted,  well  washed  in  ordinary  water. 
From  one-fourtli  of  a cubic  inch  to  one  cubic  inch  of  the  finely-minced  meat  is  placed 
in  an  ordinary  four-ounce  wide-mouthed  vial,  and  the  bottle  two-thirds  filled  with 
water,  then  from  two  to  five  grains  of  a good  quality  of  pepsine  and  from  five  to  fifteen 
drops  of  strong  hydrochloric  acid  are  added.  The  vial  is  then  corked  and  well  shaken 
for  a few  moments,  and  set  aside  in  some  place  where  the  temperature  is  about  100°  F. 
A temperature  of  120°  F.  will  effect  the  solution  of  the  meat  much  more  rapidly,  par- 
ticularly if  the  vial  is  frequently  and  thoroughly  shaken. 

Of  course,  it  would  be  more  satisfactory  to  use  a water  bath  and  thermometer,  but 
these  are  by  no  means  essential. 

The  vial  is  occasionally  shaken  until  the  mentis  all  dissolved,  which  will  require 
from  two  to  three  hours.  The  meat  solution  is  then  poured  into  a conical  champagne 
glass,  similar  to  that  used  in  urinary  analysis,  and  half  its  bulk  of  water  added.  The 
specific  gravity  of  the  trichina)  being  much  higher  than  that  of  the  diluted  meat  solu- 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  613 


tion,  they  sink  rapidly  to  the  conical  point  of  the  precipitating  glass  and  may  be  easily 
removed  by  means  of  a pipette,  transferred  to  a slide  and  examined.  And  if  the  exam- 
iner will  take  the  trouble  to  make  for  himself  a simple  hot  stage,  costing  about  ten 
cents,  similar  to  the  one  which  I exhibit  to-day,  he  will  have  the  pleasure  of  seeing 
the  worms  alive  and  moving  actively,  under  a power  of  from  twenty  to  sixty  diameters. 
There  is  another  advantage  in  the  use  of  the  hot  stage  in  making  the  examination, 
which  is,  that  a person  possessing  only  sufficient  knowledge  of  microscopical  technique 
to  focus  a microscope,  must  inevitably  detect  the  worms,  when  seen  alive  and  active, 
as  I demonstrate  them  to  you  to-day. 

In  conclusion,  I claim  for  this  method  of  examination  the  following  advantages, 
viz. : — 

1.  The  greater  part  of  the  work  of  the  examination  can  he  performed  by  a person 
possessing  no  knowledge  whatever  of  the  use  of  the  microscope. 

2.  The  certainty  with  which  the  examiner  can  state  positively  that  a given  specimen 
of  meat  does  or  does  not  contain  trichinse,  as  it  would  he  quite  possible,  in  examining 
a pound  of  meat  containing  but  one  solitary  trichina,  to  bring  that  one  worm  with  very 
little  labor  to  a certain,  definite,  predetermined  spot,  where  it  could  easily  be  found. 

3.  The  ease  with  which,  for  scientific  purposes,  the  exact  number  of  trichinse  con- 
tained in  a cubic  inch  of  meat  can  be  ascertained. 


[abstract.] 

THE  INFLUENCE  OF  EASY  CIRCUMSTANCES  ON  THE  PROLONG- 
ATION OF  LIFE. 

LTNFLUENCE  DU  BIEN  ETRE  DANS  LA  PROLONGATION  DE  LA  VIE. 

UBER  DEN  EINFLUSS  EINER  SORGENFREIEN  EXISTENZ  AUF  DIE  VERLANGERUNG  DES 

LEBENS. 

BY  C.  R.  DRYSDALE,  M.D., 

Of  London,  England. 

In  the  numerous  discussions  on  mortality  statistics  which  have  taken  place  for  some 
years  past,  it  has  been  the  custom  to  speak  as  if  the  main  points  in  sanitation  were  to  attend 
to  the  drainage  and  water  supply  of  cities  and  villages  and  to  get  rid  of  the  other  Isedentia 
in  the  shape  of  zymotic  diseases.  To  many  this  is  the  alpha  and  omega  of  sanitary  art. 
For  my  part,  I am  convinced  that  there  are  essential  points  in  the  question  of  longevity 
which  require  more  attention  than  even  these  very  important  topics,  for,  in  my  capacity 
as  physician  to  one  of  the  free  hospitals  of  London,  greatly  attended  by  the  poorer  classes, 
I have  seen  an  immense  amount  of  preventable  mortality  which  I could  attribute  to 
nothing  more  than  bad  living,  had  shelter,  and  poor  clothing.  M.  Villerm6,  of  Paris, 
one  of  the  earliest  writers  on  hygienic  science,  found,  in  his  day,  that  in  France  per- 
sons between  the  ages  of  40  and  50  years,  when  in  easy  circumstances,  had  a death 
rate  of  8.3  per  1000,  against  18.7  per  1000  in  a similar  group  of  ages  among  the  poor. 
He  found,  too,  that  in  Paris,  between  1817  and  1836,  1 in  15  of  the  poor  population  of 
the  twelfth  arrondissement  died,  against  1 in  G5  in  the  rich  or  second  arrondissement. 
In  1887,  when  I was  at  the  International  Hygienic  Congress  at  Paris,  I received  from 


614 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


Mr.  Edwin  Chadwick’s  hand  some  statistics  about  London,  collected  by  himself,  which 
showed  that  there  were  sub-districts  in  that  city  containing  houses  in  good  condition 
where  the  death  rate  was  not  over  11.3  per  1000,  while  there  were  other  sub-districts  in 
the  same  district  (slums)  where  the  death  rate  was  as  high  as  38  per  1000,  and  even  as 
50  per  1000.  That  distinguished  hygienist,  in  1843,  when  the  mean  death  rate  of  all 
London  was  24  per  1000,  found  that  in  the  parish  of  Bethnal  Green  the  mean  age  at 
death  among  the  gentry,  professioualists  and  their  families  was  44;  of  the  shopkeepers 
and  their  families,  23;  and  of  the  wage  classes,  laborers  and  their  families,  22.  It 
seems,  then,  to  me,  that  in  future  we  must  attempt  to  discriminate  more  than  has 
hitherto  been  done  in  our  mortality  statistics,  and  endeavor  to  give  the  mortality  of  the 
various  classes  according  to  their  annual  income.  Mr.  C.  Ansell,  Jr.,  Secretary  to  the 
National  Assurance  Company  of  London,  obtained,  in  the  year  1874,  statistics  of  the 
mortality  of  the  children  (no  less  than  48,000)  of  the  well-to-do  classes  in  England  and 
Wales.  The  result  of  his  inquiries  showed  that  80. 5 per  1000  of  such  children  died  in  the 
first  year  of  life.  The  death  rate  of  children  of  similar  ages  in  Liverpool  is  188,  and  in 
the  slums  of  that  aud  other  European  cities  as  many  as  330,  or  400  eveu,  of  the  children 
born  die  in  the  first  year  of  life.  Ansell  further  showed  that  the  mean  age  at  death 
among  the  richer  classes  in  England  and  Wales  was,  in  1874,  as  high  as  55;  whereas,  Dr. 
B.  W.  Richardson  and  Mr.  Chadwick,  a few  years  ago,  stated  that  the  average  age  at 
death  among  the  wage-receiving  class  in  Lambeth  was  291  years.  To  make  his  con- 
clusions more  plain,  Mr.  Ansell  calculated  that  there  died  in  1873,  in  England  and 
Wales,  386,179  persons  under  the  age  of  60;  and  if  these  all  had  had  the  mortality  of 
the  well-to-do  classes,  he  estimated  that  only  226,040  would  have  died.  Thus,  in 
one  year  poverty  had  killed  no  less  than  142,139  persous  in  England  and  Wales  alone. 
About  the  time  when  Ansell’s  tables  were  published,  in  the  healthy  colony  of  New 
Zealand,  where  food  was  so  cheap  that  a leg  of  mutton  there  sold  for  a shilling  in 
Christchurch,  the  condition  of  the  people  was  so  completely  free  from  indigence  that, 
although  there  was  a birth  rate  of  over  41  per  1000  annually,  there  was  a death  rate  of 
only  12j  per  1000.  With  a similar  death  rate  for  England  and  Wales,  230,000  lives 
would  have  been  saved  in  1873.  According  to  Dr.  Thouvenin,  in  the  Annales  d' Hy- 
giene, the  mortality  of  several  so-called  unhealthy  occupations  was  only  another  word 
for  poverty.  With  the  exception  of  cotton  beating,  dividing  and  carding  of  silk 
cocoons,  white  lead  and  grinding,  there  were  scarcely  any  trades  necessarily  dangerous 
to  life.  Tubercular  diseases,  he  found,  caused  65  per  1000  of  all  the  deaths  among  the 
rich,  and  250  per  1000  among  the  poor.  The  late  Dr.  Edward  Smith’s  statistics  at  the 
Brampton  Hospital  explained  this;  for  he  found  that  the  parents  of  the  consumptives 
attending  that  hospital  had,  on  an  average,  produced  no  less  than  7.5  children.  My 
own  hospital  experience  among  the  poor  women  in  the  East  End  of  London  fully  cor- 
roborated this,  for  I had  found  that  the  average  number  of  children  produced  by  such 
married  women  was  7.2  each.  Evidently,  such  enormous  families  cause  the  greatest 
misery  to  the  unfortunate  ehildi'en  as  well  as  to  their  reckless  parents,  for  the  child- 
ren were,  in  many  cases,  chronically  starved,  and  died  of  bronchitis  and  rickets,  in 
infancy,  in  consequence.  If  the  mortality  of  the  parishes  of  Loudon  inhabited  by  the 
wealthy,  such  as  Kensington,  with  186,684  inhabitants;  St.  George,  Hanover  Square, 
with  88,176;  Hampstead,  with  53,178;  aud  St.  James,  Westminster,  with  28,176,  were 
examined,  it  would  be  found  that,  taken  together,  these  four  rich  parishes  had  a birth 
rate  of  21.8  per  1000  and  a death  rate  of  16  per  1000;  while  four  East  End  parishes  of 
nearly  similar  population,  viz.,  Shoreditch,  with  125,508;  Bethnal  Green,  with  129,895; 
Whitechapel,  with  68,345;  and  St.  George-in-the-East,  with  46,403  inhabitants,  had  a 
birth  rate  in  1886  of  38.3  per  1000  and  a death  rate  of  24.4  per  1000.  Thus,  it  would 
appear  that  equal  populations  of  the  poor  of  Loudon  produced  about  twice  as  many 
children  as  the  rich  of  the  West  End,  and  had  a death  rate  which  was  to  that  of  the 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE. 


615 


"West  End  parishes  as  3 is  to  2.  Such  facts  are  not  comprehensible,  unless  it  be  admitted 
that  poverty  is  the  main  cause  of  high  death  rates;  and  it  is  gratifying  to  find  that  this 
fact  is  beginning  to  be  perceived  by  the  distinguished  Registrar  of  Dublin,  Ireland.  Dr. 
Grimshaw  has  observed,  in  company  with  Sir  Charles  Cameron,  of  Dublin,  that  a main 
fact  in  the  high  death-rate  of  the  city  of  Dublin  proper,  which  is  about  28  per  1000 
annually,  is  the  deplorable  poverty  of  a large  proportion  of  the  population  of  that  city, 
caused  by  the  crowding  into  the  city  from  the  country  of  very  poor  people,  many  of 
them  in  the  decline  of  life,  lured  by  the  existence  of  a host  of  hospitals  for  the  sick 
and  infirm;  for  Dublin  contains  three-fourths  of  all  the  hospital  accommodations  in  all 
Ireland.  In  a paper  read  before  the  British  Medical  Association,  in  August,  1887,  Dr. 
Grimshaw  made  the  first  accurate  attempt  to  give  the  mortality  of  the  various  classes 
in  Dublin,  and  by  dividing  the  population  (346,693)  of  Dublin  registration  district  into 
five  classes  : 1.  Professional  and  independent;  2.  Middle  class;  3.  Artisans  and  petty 
shopkeepers;  4.  General  service  class;  5.  Inmates  of  workhouses,  he  shows  that  in 
1886  the  death  rate  of  the  independent  and  professional  class  was  only  13.4  against 
33.7  in  the  fourth  and  fifth  classes  of  “general  service.”  The  number  of  children  in 
each  class,  as  given  by  Dr.  Grimshaw,  under  five  years  of  age  was,  in  class  1,  7 per 
cent. ; in  class  2,  10  per  cent. ; in  class  3,  12  per  cent. ; and  classes  4 and  5,  15  per  cent., 
which  gives,  as  in  other  cases,  twice  as  many  children  born  among  the  poor  as  among 
the  ri<  h. 

I have  already"  referred  to  the  high  death-rates  of  the  twelfth  or  poor  arrondissement 
of  Paris  (Gobelins)  as  compared  with  that  of  the  Champs  Elysees.  The  Annuaire  Sta- 
tistique  de  la  Ville  de  Paris,  of  1881,  has  explained  this  when  it  shows  that,  in  the 
Parish  of  the  Gobelins,  in  every  10,000  inhabitants  there  are  957  children  under  the 
age  of  five  against  397  in  the  Champs  Elysees.  In  the  Gobelins  there  is  one  pauper  in 
every"  nine  inhabitants. 

M.  de  Haussonville  (Rev.  d.  deux  mondes ) says  that  in  Paris,  if  statistics  were 
available  of  the  families  of  the  rich  and  poor,  it  would  be  found  that  the  number  of 
children  to  a family  among  the  latter  would  be  thrice  what  it  is  among  the  former. 
It  is,  therefore,  axiomatic  that  in  European  cities,  wherever  birth  rates  are  high,  pov- 
erty and  early  death  must  abound.  In  1877,  when  I was  Vice-President  of  one  of  the 
Sections  of  the  International  Hygienic  Congress,  I found,  by  collecting  statistics,  that 
the  average  family  of  the  medical  men  in  Paris  was  1.74  children  each;  whereas,  on 
returning  to  London,  I found  that  the  poorer  classes  in  the  East  End  produced  7.2 
children  on  an  average  each  family.  The  greatest  economist  of  our  century,  Mr.  J.  S. 
Mill,  said  that  “ little  advance  can  be  expected  in  morality  until  the  producing  of  large 
families  is  regarded  in  the  same  light  as  drunkenness  or  any  other  physical  excess;” 
and  all  enlightened  hygienic  inquirers  must  surely  agree  with  this  when  they  read  the 
statistics  above  cited.  But  if  they  do  agree  with  Mr.  J.  S.  Mill,  in  company  with 
myself,  what  shall  we  say  to  the  conduct  of  the  Royal  College  of  Physicians  of 
Edinburgh,  who,  in  March,  1887,  sent  a notice  to  Dr.  H.  A.  Allbut,  of  Leeds,  England, 
to  show  cause  why  he  should  not  be  deprived  of  his  license,  on  account  of  the  publica- 
tion of  a pamphlet  in  which  he  explained  to  the  public  and  the  poor  how  such  misery 
as  that  caused  by  large  families  could  be  innocently  avoided.  Such  conduct  fills  my 
mind  with  horror  and  amazement,  and  the  decision  of  that  college  betrays  an  ignorance 
of  economical  science  unpardonable  in  a learned  society.  It  is  true  that  the  Fellows  of 
the  Council  of  that  college  have  apparently  abandoned  their  hasty  and  ill-judged  perse- 
cution of  Dr.  Allbutt,  but  they  have  as  yet  tendered  him  and  the  medical  profession 
no  apology  for  their  action.  A humane  profession  like  the  medical,  I hold,  should  ever 
be  in  the  van  in  striving  to  alleviate  the  miseries  of  the  poor,  and  should  act  as  a bul- 
wark against  the  bigotry  and  narrow-mindedness  of  an  ignorant  public. 


616 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


MEMORANDA  ON  CHOLERA. 

NOTES  SUR  LE  CHOLERA. 

MEMORANDA  UBER  DIE  CHOLERA. 

BY  THOMAS  J.  TURNER,  A.M.,  M.D.,  PH.D., 

SleJical  Director  U.  S.  N. 

The  latest  suggested  modes  for  the  treatment  of  cholera,  as  gleaned  from  the  most 
recent  articles  in  the  journals,  can  he  grouped  under  two  classes. 

1.  Those  based  upon  the  indications  furnished  by  the  symptomatic  phenomena  in 
the  various  stages  of  that  disease,  and 

2.  Those  based  upon  and  addressed  to  the  present  received  aetiology  of  the  disease. 

Those  of  the  first  class  are  as  follows  : — 

Chapman — “ Cholera  curable” — considers  all  medication  as  useless  or  worse.  Dur- 
ing the  height  of  the  disease  absorption  is  checked  and  medicines  accumulate  to  work 
with  injurious  effect  later.  His  treatment  is  entirely  on  the  neuro-dynamic  theory. 
In  the  cold  stage,  by  the  use  of  cold  to  the  spine,  the  central  vasomotor  mechan- 
isms are  depressed,  the  capillaries  dilate  and  warmth  is  restored.  In  the  reactionary 
fever,  hot  applications  to  the  spine  stimulate  the  vasomotor  centres  and  the  capillaries 
are  contracted. 

Jessop  quotes  Hall’s  hypodermatic  chloral  treatment.  The  theory  of  this  treatment 
is  that  the  vasomotor  spasm  of  the  arterioles  is  relieved  and  the  superficial  capillaries 
are  filled. 

Bouveret  speaks  highly  of  the  intravenous  injection  of  artificial  serum.  The  fluid 
acts  by  filling  the  vessels,  thinning  the  blood  and  by  distention,  stimulating  the  heart. 
500-1000  cc.  of  the  fluid  at  39°  C.  is  used  at  a time  and  repeated  if  necessary. 

The  treatment  did  not  appear  to  result  successfully,  though  there  was  always  tem- 
porary, in  some  cases  extraordinary,  improvement. 

Bouveret  has  abandoned  the  use  of  opium  entirely.  Dr.  Cuneo  agrees  with  Bouveret 
in  this  respect.  Iu  the  early  stages  of  the  diarrhoea  Bouveret  uses  the  following  for- 


mula : — 

R.  Sirop  de  menthe 25  cc. 

Elixir  de  garus 15  cc. 

Ricini  ol 8 cc. 

Calcii  phosphas 1 grin. 

Aqua 100  cc. 


He  finds  the  calcium  phosphate  more  effective  than  any  other  astringent.  The 
above  formula  stops  the  diarrhoea  promptly,  though  vomiting  may  continue  and  require 
treatment  of  itself.  For  the  hepatic  pains  belladonna  and  mercury  treatment  are  used 
locally,  or  ol.  tiglii  over  the  liver.  The  cramps  are  relieved  by  frictions  with  camphor- 
ated oil.  Medication  may  be  continued  by  the  lower  bowel,  after  the  small  intestine 
ceases  to  absorb  anything.  He  explains  the  injurious  effect  of  opium  and  the  good 
effect  of  atropia  in  the  following  manner.  The  serous  effusion  is  caused  by  spasm  of 
the  villi  of  the  intestine,  which  squeezes  out  the  fluid  constituents  of  the  blood  ; this 
spasm  is  relieved  by  atropia  but  increased  by  opium  (?). 

RESUMiS  OF  BOUVERET’ S TREATMENT. 

1.  In  the  prodromic  stage,  mild  laxatives  and,  if  necessary,  emetics. 

2.  Iu  the  first  stage,  after  diarrhoea  has  begun,  laxatives  continued  and  antacids. 

No  alcohol  is  used,  since  it  causes  erethism  and  increases  spasm. 


SECTION  XV — PUBLIC  AND  INTERNATIONAL  HYGIENE.  G17 


3.  In  further  advanced  stage  continue  laxatives.  Apply  heat  externally  with  tonic 
lavements  and  keep  patient  still. 

4.  When  the  internal  temperature  is  great,  cold  affusions  and  cold  compresses  to  the 
abdomen. 

5.  No  food,  no  excitants.  Water  should  he  carefully  permitted — by  spoonful — in 
spite  of  thirst. 

Eouvier,  of  the  French  Navy,  has  used  intravenous  injections  of  saline  fluids  exten- 
sively and  claims  excellent  results. 

The  iudications  for  the  injections  are  dry,  wrinkled  skin,  cold  extremities,  imper- 
ceptible pulse  aud  other  evidences  of  collapse.  After  the  injections,  the  heart  resumes 
its  beating  with  satisfactory  results  and  force,  temperature  rises  to  normal  or  nearly  so, 
and  the  intellect  returns.  The  injections  are  entirely  harmless  ; no  bad  results  have 
ever  been  seen  in  his  cases,  beyond  two  insignificant  superficial  abscesses  at  the  point  of 
injection,  although  he  has  injected  2000  cc.  at  one  time  and  4800  cc.  in  the  course  of  two 
hours.  With  this  method  of  treatment,  Rouvier  claims  to  have  saved  33  per  cent,  of 
cases  considered  hopeless  by  other  physicians.* 

Kuzman  believes  that  opium  is  useful  but  should  be  carefully  used. 

C.  Jlaedowell.  For  intravenous  injection.  An  artificial  serum  made  in  the  propor- 
tion of  one  to  two  grains  of  salt  to  one  oz.  of  distilled  water,  and  injected  at  a tempera- 
ture of  39°  C.  (Koch),  au  aspirator  needle,  rubber  tube  and  a syringe  or  fuunel,  are  all 
that  are  necessary.  The  procedure  is  so  simple  that  any  hospital  attendant  can  do  it. 
The  veins  at  the  bend  of  the  elbow  are  the  most  convenient. 

Peritoneoclysis.  For  peritoneal  injections  a blunt  tube  with  the  eye  on  the  side,  like 
a catheter,  or  a small  catheter  should  be  used.  The  tube  or  catheter  is  inserted  through 
an  opening  made  with  a kuife  in  the  linea  aspera. 

Hypodermoclysis.  The  fluid  may  also  be  injected  into  the  cellular  tissue  of  the 
arms,  legs  or  abdomen,  producing  an  artificial  anasarca,  which  is  readily  absorbed.  Not 
more  than  .2  of  the  body  weight  should  be  injected  at  one  time,  aud  the  rate  of  intra- 
venous injection  should  not  exceed  five  to  nine  cc.  per  second,  for  fear  of  embarrassing 
the  heart. 

Yesicoclysis.  This  was  practiced,  as  well  as  the  two  former  methods,  by  Dr.  Richard- 
son in  1854,  but  with  less  satisfactory  results  than  the  other  methods,  from  slowness  of 
absorption. 

Warm  nutrient  fluids  may  be  injected  into  the  peritoneum  without  serious  risk,  e.y., 
defibrinated  blood,  solution  of  egg-albumin  or  milk.  In  France  intra-peritoneal  injec- 
tions of  defibrinated  blood  were  made  by  Dubar  and  Remey,  in  a number  of  cases,  and 
in  only  one  did  fatal  peritonitis  ensue.  In  this  case  the  injection  was  made  too  rapidly. 

Koch  maintains  that  the  bacillus  dies  in  a short  time,  and  if  the  patient  can  be  tided 
over  the  period  of  collapse  by  warm  injections,  simple,  medicated  or  nutrient,  as  de- 
scribed above,  the  patient  will  rally  and  tend  to  recover.  He  also  found  that  the 
“comma  bacillus”  was  antagonized  and  killed  out  by  the  “bacterium  of  putrefaction.” 
Hence  germicides  that  kill  the  latter  may  be  worse  than  useless.  Unless  germicides 
are  very  powerful  they  only  check  the  development  of  the  cholera  germ  for  a time. 

Those  of  the  second  class  are  as  follows  : — 

Accepting  the  statements  of  Koch  aud  others,  that  the  cause  of  cholera  is  to  be  found 
in  the  “comma  bacillus,”  the  therapeusis  founded  on  this  resolves  itself  into  the  use  of 
germicides  to  destroy  the  spirillum,  and  in  addition  agents  to  neutralize  the  products 
manufactured  by  this  organism.  For  these  purposes  minute  doses  of  the  bichloride  of 


* It  has  been  found  by  other  observers,  in  cases  of  hemorrhage,  that  fluid  will  bo  taken  up 
from  the  subcutaneous  areolar  tissue  of  the  abdomen  almost  as  rapidly  as  it  can  bo  injected  into 
the  veins.  This  fact  might  be  applied  in  cholera  when  intravenous  injection  was  objectionable. 


618 


NINTH  INTERNATIONAL  MEDICAL  CONGRESS. 


mercury,  and  other  articles  of  the  materia  medica  of  antiseptic  character,  have  been 
successfully  used,  and  to  neutralize  the  products,  the  mineral  acids,  more  especially 
sulphuric  acid. 

Treatment  based,  as  this  is,  upon  the  {etiology  of  the  disease  is  rational  in  character, 
extending  as  it  does  to  the  destruction  of  the  cause,  antecedent  to  its  effects,  as  mani- 
fested in  the  phenomena  of  cholera  and  addressed  during  the  presence  of  such,  to  the 
like  indication.  To  the  empirical  treatment,  such  as  is  grouped  in  the  first  class,  must 
be  added  the  suggested  use  of  pilocarpin,  as  affecting  the  functions  of  the  skin,  and 
founded  upon  the  physiological  antagonism  of  the  skin  and  the  intestinal  mucous  sur- 
face. 

It  is  in  the  management  of  the  premonitory  diarrhoea  that  successful  results  are  to 
be  attained. 

Chauveau  considers  the  experiments  of  Ferran,  in  the  preventive  inoculation  for 
cholera,  worthy  of  serious  consideration  and  further  study. 

Godoy  found  that  out  of  the  body,  the  vapor  of  sulphuric  ether  was  quickly  fatal  to 
the  cholera  bacillus,  and  applied  this  fact  to  the  treatment  of  the  disease.  The  ether 
vapor  was  injected  into  the  rectum  and  its  effects  arrested  short  of  anaesthesia.  The 
final  results  were  not  particularly  striking,  although  the  conditions  of  the  patient 
improved  and  the  bad  symptoms  abated  after  the  injections. 

Cantani  claims  to  have  reduced  the  mortality  one-half,  in  severe  cases,  by  means  of 
injections  of  tannic  acid  with  opium  into  the  rectum,  forcing  the  fluid  past  the  ileo- 
caecal  valve,  and  even  into  the  stomach.  He  used  the  following  formula:  1500  to  2000 
cc.  of  sterilized  water,  3 to  20  grammes  of  tannic  acid  and  30  drops  of  tincture  of 
opium.  This  was  injected  from  two  to  six  times  daily.  Its  efficacy  is  thought  to  be 
due  to  the  germicidal  properties  of  the  tannic  acid. 

In  the  premonitory  diarrhoea  and  to  promote  reaction,  the  following  formula  has 
met  with  universal  approval  in  England  and  India,  and  is  directed  by  authority  to  be 
kept  in  store  in  the  army,  and  with  troops  on  the  march  : — 


The  dose  of  this  mixture  is  ten  drops  every  quarter  of  an  hour  in  a tablespoonful  of 
water. 


* The  liq.  acid.  Haller  consists  of  one  part  of  concentrated  sulphuric  acid  to  three  parts  of 
rectified  spirit,  and  the  tincture  of  cinnamon  is  made  by  dissolving  one  fluid-drachm  of  the  oil  of 
cinnamon  in  two  fluid  ounces  of  stronger  alcohol. 


R.  01.  anisi, 

01.  cajuput., 

Ol.  juniper 

Ether 

Liq.  acid.  Haller* 
Tinct.  cinnamom., 


aa 


INDEX  TO  VOLUME  IV 


Address  by  Pres,  of  Sec.  XIII  (Dr.  W.  II. 

Daly),  2. 

XIV  (Dr.  A.  R. 
Robinson),  156. 

XV  (Dr.  Joseph 
Jones),  294. 

Air  passages,  effect  of  tobacco  on,  101. 

galvano-cautery  in  diseases  of,  60. 
recurrent  hemorrhage  of,  45. 
Allen,  Dr.  C.  Slover,  113,  133. 

Alopecia,  areata,  pathology  and  treatment  of, 
241. 

Antiseptics,  actual  value  of,  608. 


Bailhache,  Surgeon  P.  H.,  488,  494. 

Beirut,  Syria,  dengue  in,  466. 

Bell,  Dr.  A.  N.,  475,  529,  565,  581. 

Benham,  Dr.  S.  N.,  48,  58,  70. 

Bermann,  Dr.  I.,  5,  66. 

Browne,  Dr.  Walton,  6. 

Dr.  Lennox.  2,  6,  13,  19,  30,  44,  46,  80, 
88,  103,  105,  132. 

Byrd,  Dr.  D.  E.  434. 


Canned  goods,  danger  of,  to  public  health,  610. 
Carbolic  acid  as  an  antiseptic  and  germicide, 
607. 

Carter,  Dr.,  168. 

Casselberry,  Dr.  W.  E.,  14,  29,  42,  44,  72,  81,  99. 
Catarrh,  nasal,  resorcin  iD,  56. 

Cholera  infantum,  influence  of  climate  in  pro- 
duction of,  534. 
memoranda  on,  616. 

Chorea  laryngis,  82. 

Climate,  influence  of  in  production  of  cholera 
infantum,  534. 

Close,  Dr.  James  A.,  612. 

Coghill,  Dr.  J.  S.,  26,  30. 

Cohen,  Dr.  J.  Solis,  2,  14,  27,  43,  46. 

Comedo,  double,  study  of,  230. 

Cook,  Dr.  Wm.  C.,  587. 

Coomes,  Dr.  M.  F.,  6,  18,  28,  80,  100,  101,  103. 
Cough,  nervous,  and  its  treatment,  133. 
Crudeli,  Dr.  C.  T.,  530. 

Curtis,  Dr.  H.  H.,  48. 

Dr.  Lester,  29. 

Cutter,  Dr,  E.,  67,  88,  105. 

Cystic  goitre,  new  treatment  of,  114. 


Daly,  Dr.  W.  II.,  1,  2,  70,  153. 
Davies,  Dr.  G.,  192. 

Davis,  Dr.  N.  S.,  593. 

Dr.  R.  C.,  456,  593. 

Day,  Dr.  Richard  II.,  425,  435. 


De  Amicis,  Dr.  Tomasso,  275. 

Dengue  in  Beirut,  Syria,  epidemiological  notes 
on,  466. 

Dennison,  Dr.  C.,  99. 

Dermatology  and  syphilography  (Sec.  XIV), 
officers,  list  of,  155. 

Desvernine,  Dr.  C.  N.,  115. 

Diphtheria,  sulphuret  of  lime  in,  151. 
Disinfectant,  steam  as  a,  565. 

Drysdale,  Dr.  C.  R.,  613. 


Eaton,  Dr.  F.  B.,  60. 

Eczema,  seborrhceic,  215. 

Education,  place  of  sanitary  science  in,  443. 
Egypt,  modern,  hygiene  in,  436. 

Elephantiasis  arabum  in  children,  271. 
Endemic  and  epidemic  diseases,  causes  and 
prevention  of,  495. 

Epiglottis,  action  of,  in  swallowing,  111. 
Epistaxis,  4. 

Fibromata,  nasal,  72. 

Formento,  Dr.  Felix,  487,  4S8,  532. 

Fort  Jackson,  on  Savannah  river,  table  of  dis- 
eases at,  525. 

Foster,  Dr.  John  F.,  6. 

Fox,  Dr.  R.  K.,  533. 

Freirc,  Dr.  D.,  475,  487,  488. 


Galvano-cautery  in  diseases  of  upper  air  pas- 
sages, 60. 

Gaston,  Dr.  J.  MeF.,  488. 

Germicidal  and  antiseptic  powers  of  certain 
mineral  and  vegetable  substances,  593. 

Goitre,  cystic,  new  treatment  of,  114. 

Gottheil,  Dr.,  169,  185,  229. 

Grant-Bey,  Dr.  J.  A.  S.,  433,  436,  471,  581. 

Great  Britain,  growth  of  preventive  medicine 
in,  472. 


Hay-fever,  causes  and  treatment  of,  7,  11. 
Hazlewood,  Dr.  A.,  457. 

Health,  effect  of  overflow  of  Mississippi  river 
and  rice  culture  upon,  425. 
public,  danger  to,  from  canned  goods, 
610. 

Hebert,  Dr.  Thomas,  541,  547,  582. 
Hemorrhage  of  air  passages,  45. 

Hirsuties,  studies  in,  180. 

Hobbs,  Dr.  A.  G.,  31. 

Hygiene,  domestic,  297. 

germicidal  and  antiseptic  powers  of 
certain  substances  in,  593. 


619 


G20 


INDEX  TO  VOLUME  IV. 


Hygiene  in  modern  Egypt,  436. 
international,  320. 
necessity  of  teaching  in  schools,  587. 
public  and  international  (Dr.  Jos. 
Jones),  293,  294. 

public  and  international  (Dr.  U.  It. 

Milner),  458. 
public  and  national,  302. 
resolution  relative  to,  592. 
Hypodermic  injection  in  treatment  of  syphilis, 
225. 


Impetigo  herpetiformis,  193. 

Infectious  diseases,  metropolitan  defenses 
against,  491. 

Ingals,  Dr.  Fletcher,  4,  6,  13,  27,  33,  42,  44, 
81,105,113,  115,  153. 

Injection,  hypodermic,  in  treatment  of  syphilis, 
225. 

Inoculation  with  attenuated  culture  of  yellow- 
fever  microbe,  475. 

Inspection,  sanitary,  of  passenger  coaches,  548. 

Intubation  in  tracheotomy,  89. 
of  larynx,  121. 

Jones,  Dr.  Camalt,  111. 

Dr.  Joseph  (President  Sec.  XV),  293, 
294,  435,  475,  487,  495,  532,  540,  581, 
593. 

Juler,  Dr.  Henry  C.,  168. 


Keller,  Dr.  Jas.  M.,  169. 

Klingensmith,  Dr.  I.  P.,  11. 

Klotz,  Dr.  H.  G.,  172,  173,  205,  229. 

Knaggs,  Dr.  Valentine,  186,  204,  269. 

Knight,  Dr.  Win.,  168. 

Koser,  Dr.  S.  S.,  15. 

Laborde,  Dr.  F.  de  Winthuysen,  151. 
Ladmirault,  Dr.,  610. 

Laryngeal  chorea,  82. 

phthisis,  clinical  report  on  treatment 
of,  38. 

Laryngitis  rheumatic,  33. 

Laryngology,  Sec.  XIII,  officers,  list  of,  1. 
Laryngoscopical  work  in  Mexico,  58. 

Larynx,  and  throat,  tuberculosis  of,  19. 
intubation  of,  121. 
papillomata  of  42. 
primary  erysipelas  of,  67. 
table  of  diseases  of,  41,  42. 
tuberculous,  specific  and  rheumatic 
diseases,  diagnostic  differentiation 
of,  38. 

Lathrop,  Dr.  M.  C.,  169. 

Lee,  Dr.  Benjamin,  592. 

Leighton,  Dr.  A.  W.,  443. 

LeMonnier,  Dr.,  423,  424. 

Life,  easy  circumstances  in  prolongation  of,  613. 
Lime  sulphuret  in  diphtheria,  151. 

Lindsley,  Dr.  J.  B.,  424. 

Lupus  erythematosus,  198. 

of  hands,  206. 
tables  of,  210,  211. 

MacGeagh,  Dr.  T.  E.  F.,  28. 

Malaria,  nature  and  prophylaxis  of,  530. 


Malarial  fever,  chemical  and  microscopical  char- 
acters and  changes  in  blood  of, 
495. 

differentiation  from  enteric,  541. 
history  and  treatment  of,  in 
Texas,  541. 

jurisprudence  and  diagnosis  of, 
495. 

relation  of  soil  drainage  to,  582. 
Martin,  Dr.  J.  A.,  586. 

Mason,  Dr.  Geo.  W.,  15. 

Massei,  Prof.  F.,  67. 

Maxwell,  Dr.  Geo.  T.,  423,  434,  457,  534,  540. 
McGuire,  Dr.  Hunter,  192. 

McKenzie,  Dr.  John  N.,  14,  29. 

Dr.  Morel!,  2. 

McLaughlin,  Dr.  James  W.,  469. 

Meat,  detection  of  trichina  spiralis  in,  612. 
Medicine,  preventive,  growth  of,  in  Great  Brit- 
ain, 472. 

Melanosis  of  skin,  unique  case  of,  269. 
Mercuric  chloride,  comparison  with  carbolic 
acid,  607. 

Mercury,  hypodermic  injection  of,  in  syphilis, 
225. 

Mexico,  laryngoscopical  work  in,  58. 

Microbe  of  yellow  fever,  inoculation  with,  475. 
Milner,  Dr.  N.  R.,  458,  533. 

Mineral  and  vegetable  substances,  germicidal 
and  antiseptic  powers  of,  593. 

Mississippi  river,  overflows  of,  effect  on  public 
health,  425. 

Moncorvo,  Dr.,  271. 

Moura,  Dr.  F.,  143. 

Muscles  of  organ  of  voice,  143. 

Mycosis  fungoides,  existence  of  parasites  in,  275. 

Nasal  fibromata,  72. 

tables  of,  78,  79. 
stenosis,  48. 

Nash,  Dr.  A.,  586. 

Neoplasms,  benign,  supraepiglottic,  114. 
Nervous  phenomena  in  exposure  of  spinal  cord, 
etc.,  31. 

New  Orleans,  La.,  mortality  tables  of,  306,  310. 


O’Dwyer,  Dr.  Joseph,  121,  132. 
Ohmann-Dumesnil,  Dr.  A.  H.,  206,  230,  240. 

Paine,  Dr.  J.  F.  Y.,  470. 

Papillomata,  laryngeal,  treatment  of,  42. 
Parasite  in  mycosis  fungoides,  275. 

Parasitic  diseases  of  skin,  treatment  of,  1S9. 
Parker,  Dr.  Rogers,  169. 

Passenger  coaches,  chemical  examination  of 
water  in,  555. 
sanitary  inspection  of,  548. 
table  of  carbon  dioxide  in 
air  of,  555. 

Phonation,  relation  to  cantation,  105. 

Porter,  Dr.  Win.,  44,  45,  105,  153. 

Quarantine,  323. 

Rankin,  Dr.  D.  N.,  16,  153. 

Ravogli,  Dr.  Augustus,  185, 192,  204,  205,  269. 
Rectal  alimentation  in  diseases  of  skin,  170. 
Redard,  Dr.  M.  P.,  581. 


INDEX  TO  VOLUME  IV. 


621 


Reed,  Dr.  R.  H.,  528,  510,  548. 

Resolution  on  publication  of  papers,  105. 

relative  to  teaching  hygiene  in 
schools,  592. 

Resorcin  in  nasal  catarrh,  50. 

Reynolds,  Dr.  H.  J.,  185,  189,  192,  268. 
Rheumatic  laryngitis,  33. 

Rhinology,  history  of,  10. 

Rice  culture,  effect  on  public  health,  425. 
Richardson,  Dr.  B.  W.,  472,  475. 

Ridge,  Dr.  Jas.  M.,  15. 

Robinson,  Dr.  A.  R.,  155,  156,  169,  205,  241, 
269,  292. 

Roe,  Dr.  John  O.,  82,  88. 

Rohe.  Dr.  Geo.  H.,  180,  186,  192. 

Rosenbach,  Dr.  Ottomar,  133. 


Sanitary  science,  place  of,  in  education,  443. 
Savannah,  Ga..  mortality  tables  of,  305. 
Schenck,  Dr.  W.  L.,  423,  457,  586. 

Schools,  necessity  of  teaching  hygiene  in,  587. 

resolution  relative  to  teaching  hygiene 
in,  592. 

Scott.  Dr.  W.  J.,  565. 

Seaton,  Dr.  Edward,  491. 

Section  XIII  (Laryngology),  officers,  list  of,  1. 

XIV  (Dermatology  and  Syphilography) 
officers,  list  of,  155.  ' 

XV  (Public  and  International  Hy- 
giene), officers,  list  of,  293. 

Semelder,  Dr.  F.,  58. 

Shoemaker,  Dr.  Jno.  V.,  170,  173. 

Shurley,  Dr.  E.  L.,  38,  42- 

Skin  diseases,  rectal  alimentation  in,  170. 

local  treatment  of,  186. 
melanosis  of,  269. 
ulcers  of,  in  syphilis,  173. 

Snare  and  ecraseur,  133. 

Soil  drainage  and  other  methods  in  relation  to 
malarial  fever,  582. 

Spinal  cord,  exposure  of,  from  syphilitic  ulcera- 
tion of  upper  pharynx,  nervous  phenomena 
in,  31. 

Steam  as  a disinfectant,  565. 

Stenosis,  nasal,  48. 

Stern,  Dr.  Max  J.,  89,  101. 

Stockton,  Dr.  Frank  0.,  15,  29,  38,  46,  70,  81, 
103,  111,  113,  115. 

Stucky,  Dr.  Jos.  A.,  14,  37,  38,  57. 

Syphilis,  treatment  of,  by  injection  of  mercury, 
225. 

ulcers  of  skin  in,  173. 


Table  of  carbon  dioxide  in  air  of  passenger 
coaches,  555. 

cases  of  nasal  fibromata,  78,  79. 


Table  of  chemical  examination  of  water  in 
passenger  coaches,  555.  ' 
disease,  Fort  Jackson,  on  Savannah 
river,  525. 

Tables  of  lupus  erythematosus,  210,  211. 

mortality  (New  Orleans),  306,  310. 
(Savannah,  Ga.),  305. 
yellow  fever,  386,  387,  422. 
vaccination  in  variola,  163-168. 
symptoms  of  tuberculous,  syphilitic  and 
rheumatic  diseases  of  larynx,  41,  42. 
Taylor,  Dr.  B.  D.,  533,  540,  541. 

Dr.  M.  K.,  487,  532,  533. 

Temperature  chart,  562-564. 

Texas,  malarial  fever,  history  and  treatment  of, 
in,  541. 

Thin,  Dr.  Geo.,  184,  191,  204,  241,  267. 
Thomas,  Dr.  Richard  H.,  7,  15,  60,  67. 
Thorner,  Dr.  Max,  28,  88. 

Thrasher,  Dr.  A.  B.,  56,  113. 

Tobacco,  effect  of,  on  air  passages,  101. 
Toeplitz,  Dr.  Max,  67,  70. 

Trichina  spiralis,  detection  of,  in  meat,  612. 
Tuberculosis,  throat  and  larynx,  pathology  and 
treatment  of,  1 9. 

Turner,  Thomas  J.,  Med.  Director,  U.  S.  Navy, 
616. 


Ulcers  of  skin  in  syphilis,  173. 

Unna,  Dr.  P.  G.,  172,  179,  184,  189,  198,  204, 
215,  240,  266,  292. 


Vaccination  in  incubation,  period  of  variola, 
160. 

Vaughn,  Prof.  V.  C.,  540. 

Vocal  bands,  tension  of,  115. 

Von  Klein,  Dr.  R.  II.,  15. 


Walker,  Dr.  D.  R.,  532. 

Watraszewski,  Dr.  X.,  225,  230. 
Waxham,  Dr.  Frank  E.,  100. 

Welch,  Dr.  Win.  M.,  160,  169. 

Wortabet,  Dr.  John,  466. 

Wyman,  Surgeon  Walter,  M.  II.  S.,  475. 


Yates,  Dr.  James,  456. 

Yeamans,  Dr.  C.  C.,  169,  192. 

Yellow  fever,  germ  of,  475. 

microbe  of,  inoculation  with,  475. 
tables  of  mortality  in,  386,  387, 
422. 


Zeisler,  Dr.  Josef,  179,  193,  205,  225,  229,  268. 


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